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Become A Senior Claims Examiner

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Working As A Senior Claims Examiner

  • Getting Information
  • Resolving Conflicts and Negotiating with Others
  • Interacting With Computers
  • Communicating with Supervisors, Peers, or Subordinates
  • Identifying Objects, Actions, and Events
  • Unpleasant/Angry People

  • Mostly Sitting

  • Repetitive

  • Make Decisions

  • $62,980

    Average Salary

What Does A Senior Claims Examiner Do

Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim and, if so, how much.

Duties  

Claims adjusters, appraisers, examiners, and investigators typically do the following:

  • Investigate, evaluate, and settle insurance claims
  • Determine whether the insurance policy covers the loss claimed
  • Decide the appropriate amount the insurance company should pay
  • Ensure that claims are not fraudulent
  • Contact claimants’ doctors or employers to get additional information on questionable claims
  • Confer with legal counsel on claims when needed
  • Negotiate settlements
  • Authorize payments

Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. For example, workers in property and casualty insurance must know housing and construction costs to properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable. 

Adjusters inspect property damage to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.

Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.

Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.

If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer’s position.

Some claims adjusters work as self-employed public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company’s adjuster. The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.

Sometimes, self-employed adjusters are hired by insurance companies in place of hiring adjusters as regular employees. In this case, the self-employed adjusters work in the interest of the insurance company.

Appraisers estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.

Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.

Most claims examiners work for life or health insurance companies. Examiners who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator.

Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies, to make sure that the applicants have no serious illnesses that would make them a high risk to insure.

Insurance investigators handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of damage to vehicles to complicated fraud rings. Investigators often do surveillance work. For example, in the case of a fraudulent workers’ compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be ruled out by injuries stated in the claim.

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How To Become A Senior Claims Examiner

A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. Higher level positions may require a bachelor’s degree or some insurance-related work experience. Auto damage appraisers typically have either a postsecondary nondegree award or work experience in identifying and estimating the cost of automotive repair.

Education

A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. However, employers sometimes prefer to hire applicants who have a bachelor’s degree or some insurance-related work experience or vocational training. Auto damage appraisers typically have either a postsecondary nondegree award or experience working in an auto repair shop, identifying and estimating the cost of automotive repair.

The varying types of work in these occupations can require different backgrounds or different college coursework. For example, a business or an accounting background might be best for someone who wishes to specialize in claims of financial loss due to strikes, equipment breakdowns, or merchandise damage. College training in architecture or engineering is helpful for adjusting industrial claims, such as those involving damage from fires or other accidents. A legal background is beneficial to someone handling workers’ compensation and product liability cases. A medical background is useful for examiners working on medical and life insurance claims.

Although auto damage appraisers are not required to have a college education, most companies prefer to hire people who have the formal training, experience, or knowledge and technical skills to identify and estimate the cost of automotive repair. Many vocational schools and some community colleges offer programs in auto body repair and teach students how to estimate the cost of repairing damaged vehicles.

For investigator jobs, a high school diploma or equivalent is the typical education requirement. Most insurance companies prefer to hire people trained as law enforcement officers, private investigators, claims adjusters, or examiners, because these workers have good interviewing and interrogation skills.

Training

At the beginning of their careers, claims adjusters, examiners, and investigators work on small claims, under the supervision of an experienced worker. As they learn more about claims investigation and settlement, they are assigned larger, more complex claims.

Auto damage appraisers typically get on-the-job training, which may last several months. This training usually involves working under the supervision of a more experienced appraiser while estimating damage costs, until the employer decides that the trainee is ready to do estimates on his or her own.

Licenses, Certifications, and Registrations

Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state. Some states have few requirements; others require either completing prelicensing education or receiving a satisfactory score on a licensing exam (or both).

In some states, claims adjusters employed by insurance companies do not have to become licensed themselves because they can work under the company license.

Public adjusters may need to meet separate or additional requirements.

Some states that require licensing also require a certain number of continuing education credits per year to renew the license. Federal and state laws and court decisions affect how claims must be handled and what insurance policies can and must cover. Examiners working on life and health claims must stay up to date on new medical procedures and the latest prescription drugs. Examiners working on auto claims must be familiar with new car models and the most recent repair techniques. In order to fulfill their continuing education requirements, workers can attend classes or workshops, write articles for claims publications, or give lectures and presentations.

Important Qualities

Analytical skills. Adjusters and examiners must both evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay. Adjusters must carefully consider various pieces of information to reach a decision.

Communication skills. Claims adjusters and investigators must get information from a wide range of people, including claimants, witnesses, and medical experts. They must know the right questions to ask in order to gather the information they need.

Detail oriented. Adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences.

Interpersonal skills. Adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering. These workers must be understanding, yet firm with their company’s policies.

Math skills. Appraisers must be able to calculate property damage.

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Senior Claims Examiner jobs

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Senior Claims Examiner Career Paths

Senior Claims Examiner
Claim Specialist Account Manager Billing Specialist
Accounts Receivable Manager
6 Yearsyrs
Claims Supervisor Office Manager Business Office Manager
Business Office Director
8 Yearsyrs
Claim Specialist Billing Specialist
Business Office Manager
8 Yearsyrs
Billing Specialist Specialist Case Manager
Career Manager
6 Yearsyrs
Benefit Specialist Claims Representative Adjuster
Casualty Claims Supervisor
9 Yearsyrs
Claims Supervisor Claims Manager
Claims Director
12 Yearsyrs
Senior Claims Representative Claims Supervisor
Claims Manager
8 Yearsyrs
Accounts Receivable Specialist Accounting Coordinator Account Associate
Client Account Manager
6 Yearsyrs
Billing Specialist Collector
Collections Manager
5 Yearsyrs
Senior Claims Specialist Claims Supervisor Claims Manager
General Adjuster
11 Yearsyrs
Service Representative Registered Nurse Occupational Health Nurse
Health Services Manager
7 Yearsyrs
Litigation Support Specialist Adjuster Loss Mitigation Specialist
Loss Control Manager
6 Yearsyrs
Benefit Specialist Enrollment Specialist Provider Services Representative
Manager, Provider Relations
9 Yearsyrs
Claims Manager Human Resources Manager Practice Manager
Patient Services Manager
8 Yearsyrs
Account Manager Underwriter Insurance Specialist
Reimbursement Analyst
6 Yearsyrs
Senior Claims Specialist Claims Manager General Adjuster
Senior Claims Adjuster
7 Yearsyrs
Service Representative Claims Representative Claims Analyst
Senior Claims Analyst
6 Yearsyrs
Senior Claims Analyst Billing Specialist Claims Representative
Senior Claims Representative
6 Yearsyrs
Senior Claims Representative Claim Specialist
Senior Claims Specialist
7 Yearsyrs
Claims Manager Operations Manager Underwriter
Underwriting Consultant
10 Yearsyrs
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Average Length of Employment
Claims Manager 4.6 years
Claims Adjuster 3.6 years
Claim Specialist 3.2 years
Claims Adjudicator 3.2 years
Claim Processor 3.2 years
Claims Analyst 3.0 years
Claims Associate 2.8 years
Claims Reviewer 2.2 years
Top Employers Before
Adjuster 2.4%
Top Employers After
Consultant 3.0%
Supervisor 2.6%
Adjuster 2.0%

Senior Claims Examiner Demographics

Gender

Female

68.2%

Male

29.8%

Unknown

2.0%
Ethnicity

White

83.5%

Hispanic or Latino

8.5%

Asian

6.0%

Unknown

1.5%

Black or African American

0.4%
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Languages Spoken

Spanish

57.1%

Carrier

14.3%

Portuguese

3.6%

Bosnian

3.6%

Serbian

3.6%

French

3.6%

Armenian

3.6%

Tagalog

3.6%

Dakota

3.6%

Croatian

3.6%
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Senior Claims Examiner Education

Schools

University of Phoenix

18.8%

Florida State College at Jacksonville

8.6%

University of North Florida

5.5%

Nassau Community College

4.7%

Houston Community College

4.7%

California State University - Sacramento

4.7%

American Institute

4.7%

University of Washington

4.7%

Montclair State University

4.7%

California State University - Northridge

4.7%

University of Southern Maine

3.9%

Community College of Philadelphia

3.9%

University of North Texas

3.9%

California State University - Los Angeles

3.9%

Strayer University

3.1%

Ashford University

3.1%

San Francisco State University

3.1%

San Jose State University

3.1%

Johnson County Community College

3.1%

Florida State University

3.1%
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Majors

Business

33.2%

Health Care Administration

10.2%

Law

5.8%

Management

5.5%

Criminal Justice

4.8%

Accounting

4.7%

Insurance

4.3%

Psychology

3.7%

Nursing

3.3%

Finance

3.3%

Legal Support Services

3.0%

Liberal Arts

2.7%

Political Science

2.5%

Marketing

2.2%

General Studies

1.8%

Education

1.8%

Public Administration

1.8%

Communication

1.8%

History

1.8%

Medical Assisting Services

1.7%
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Degrees

Bachelors

38.1%

Other

27.7%

Masters

12.4%

Associate

9.2%

Certificate

7.1%

Doctorate

3.0%

Diploma

1.8%

License

0.7%
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Job type you want
Full Time
Part Time
Internship
Temporary

Top Skills for A Senior Claims Examiner

CustomerServiceClaimsExaminerMedicalProvidersMedicalTreatmentDisabilityClaimsMedicalClaimsBodilyInjuryClaimsComplianceMedicaidProcessClaimsGeneralLiabilityClaimsAutoMedicalRecordsIndependentAdjustersComplexClaimsCPTInsuranceClaimsDentalClaimsDataEntryAdjudicateClaims

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Top Senior Claims Examiner Skills

  1. Customer Service
  2. Claims Examiner
  3. Medical Providers
You can check out examples of real life uses of top skills on resumes here:
  • Developed superior communication and customer service skills through consistent interaction with a variety of internal and external contacts.
  • Answered phone calls and processed 150+ claims per day as Senior Claims Examiner, consistently exceeding daily/weekly/monthly goals.
  • Communicated with injured workers, employers, attorneys, vendors and medical providers.
  • Discussed appropriateness of medical treatment with medical case managers.
  • Adjudicated disability claims based on information from customers and medical documents/records.

Top Senior Claims Examiner Employers