What does a worker's compensation claims examiner do?
Worker's Compensation Claims Examiners are responsible for managing the overall process of compensation claims for workers. They review accurate submission of claim documents, determine the appropriateness of compensation, and finalize the amount before authorizing payment to the respective worker. Other duties include ensuring claims adhere to workers' compensation law and follow proper guidelines. A Worker Compensation Claims Examiner normally work for life insurance or health companies.
Worker's compensation claims examiner responsibilities
Here are examples of responsibilities from real worker's compensation claims examiner resumes:
- Manage all aspects of claims, including heavy litigation and vocational rehabilitation cases.
- Negotiate settlements and actively manage the litigation process and process complex and technically difficult claims.
- Determine benefits when processing medical claims receive as HCFA and UB92 paper claims or electronically.
- Set up vehicle inspections, and rental reservations as a part of the claim settlement process.
- Handle incoming calls from customers and providers with policy changes and claim status updates and maintain HIPAA.
- Process claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements and Medicaid claims.
- Process paper claims and electronic work queues, including HCFA 1500 and UB92, in accordance with company policies and procedures.
- Safeguard confidential information per HIPAA laws.
- Perform PPO re-pricing and administer coordination of benefits.
- Investigate and resolve litigation issues with critical thinking analysis, problem-solving, strategic planning, and decision-making.
- Receive and review of incoming medical and hospital claims for Medicaid/Medicare replacement plan, for compliance with establish policies and procedures.
- Work on several special projects after hours and on weekends to help meet state and EDI filing requirements.
- Negotiate settlements and file arbitration or hire counsel when warrant.
- Handle and attend arbitrations and mediations for litigate claims.
Worker's compensation claims examiner skills and personality traits
We calculated that 22% of Workers's Compensation Claims Examiner are proficient in Rehabilitation, Social Security, and Litigation. They’re also known for soft skills such as Analytical skills, Communication skills, and Detail oriented.
We break down the percentage of Workers's Compensation Claims Examiner that have these skills listed on their resume here:
- Rehabilitation, 22%
Attended rehabilitation conferences before the Rehabilitation Bureau and participated in informal conferences via telephone conference calls.
- Social Security, 16%
Settled complex claims involving pension offsets, Social Security Disability offsets and Medicare involvement.
- Litigation, 15%
Worked collaboratively with attorneys to draft settlements and assisted with litigation strategies.
- Medical Management, 9%
Coordinate medical management of claims.
- Workers Compensation Claims, 9%
Investigated and serviced workers compensation claims in adherence to Minnesota law.
- TPA, 4%
Acted as TPA and managed a very large caseload of 450 - 500 claims that were once Reliance claims.
Common skills that a worker's compensation claims examiner uses to do their job include "rehabilitation," "social security," and "litigation." You can find details on the most important worker's compensation claims examiner responsibilities below.
Analytical skills. To carry out their duties, the most important skill for a worker's compensation claims examiner to have is analytical skills. Their role and responsibilities require that "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay." Workers's compensation claims examiner often use analytical skills in their day-to-day job, as shown by this real resume: "analyze and process worker's compensation claims, determining benefits due, negotiating settlements and managing technically difficult claims requiring litigation"
Communication skills. Many worker's compensation claims examiner duties rely on communication skills. "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts," so a worker's compensation claims examiner will need this skill often in their role. This resume example is just one of many ways worker's compensation claims examiner responsibilities rely on communication skills: "created and implemented procedures to enhance workflow, communication and customer service. "
Detail oriented. workers's compensation claims examiner are also known for detail oriented, which are critical to their duties. You can see how this skill relates to worker's compensation claims examiner responsibilities, because "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." A worker's compensation claims examiner resume example shows how detail oriented is used in the workplace: "compile detailed reports for quarterly client claims reviews up to 100 files per review. "
Interpersonal skills. A big part of what workers's compensation claims examiner do relies on "interpersonal skills." You can see how essential it is to worker's compensation claims examiner responsibilities because "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." Here's an example of how this skill is used from a resume that represents typical worker's compensation claims examiner tasks: "provided high quality front line customer service, communication, team interaction, and interpersonal skills. "
The three companies that hire the most worker's compensation claims examiners are:
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Worker's compensation claims examiner vs. Adjuster
An adjuster is responsible for evaluating the extent of loss in the company by calculating the damage costs, determining the settlement payment to the client, and managing the reputation of the company for claims accountability. Adjusters must have extensive knowledge of the insurance principles and processes, following the state and federal regulations to protect clients and the business from insurance fraud. They collect documents from different organizations, perform field research, and interview witnesses to verify the accuracy of claims statement.
These skill sets are where the common ground ends though. The responsibilities of a worker's compensation claims examiner are more likely to require skills like "rehabilitation," "calculates," "social security," and "litigation process." On the other hand, a job as an adjuster requires skills like "customer service," "strong customer service," "liability claims," and "policy coverage." As you can see, what employees do in each career varies considerably.
Adjusters earn the highest salaries when working in the insurance industry, with an average yearly salary of $50,894. On the other hand, workers's compensation claims examiner are paid more in the finance industry with an average salary of $87,601.On average, adjusters reach similar levels of education than workers's compensation claims examiner. Adjusters are 1.5% less likely to earn a Master's Degree and 0.2% more likely to graduate with a Doctoral Degree.Worker's compensation claims examiner vs. Insurance adjuster
An appraiser is someone who assesses the monetary value of a property such as an automobile, real property, and personal claim. His/Her or her responsibilities include resolving disparities between a property's monetary values and preparing narrative reports for projects. The essential skills that an appraiser should possess to accomplish such responsibilities include a keen eye for details, strong communication, analytical, and problem-solving skills, and the ability to work under pressure. The education requirements for the job vary depending on the area of focus.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that worker's compensation claims examiner responsibilities requires skills like "rehabilitation," "calculates," "social security," and "litigation." But an insurance adjuster might use other skills in their typical duties, such as, "insurance policies," "customer service," "liability claims," and "auto claims."
Insurance adjusters earn a higher average salary than workers's compensation claims examiner. But insurance adjusters earn the highest pay in the insurance industry, with an average salary of $60,583. Additionally, workers's compensation claims examiner earn the highest salaries in the finance with average pay of $87,601 annually.insurance adjusters earn similar levels of education than workers's compensation claims examiner in general. They're 1.0% less likely to graduate with a Master's Degree and 0.2% more likely to earn a Doctoral Degree.Worker's compensation claims examiner vs. Appraiser
A claims specialist is responsible for processing insurance claims, reviewing insurance coverage, and analyzing claims cases. Claims specialists' duties include negotiating claims settlements, validating claims to prevent fraud, creating court testimonies as needed, developing claim review plans, and checking necessary documents and related resolve claims. A claims specialist must have strong analytical and critical-thinking skills to authorize claim payment and investigate complex and unusual claims. Claims specialists should also have extensive knowledge of the insurance processes to handle various cases, following legal policies and regulatory procedures.
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a worker's compensation claims examiner is likely to be skilled in "rehabilitation," "calculates," "social security," and "litigation process," while a typical appraiser is skilled in "commercial property," "appraisal reports," "customer service," and "mai."
Appraisers earn the highest salary when working in the insurance industry, where they receive an average salary of $48,145. Comparatively, workers's compensation claims examiner have the highest earning potential in the finance industry, with an average salary of $87,601.appraisers typically earn similar educational levels compared to workers's compensation claims examiner. Specifically, they're 0.3% more likely to graduate with a Master's Degree, and 0.0% more likely to earn a Doctoral Degree.Worker's compensation claims examiner vs. Claim specialist
Types of worker's compensation claims examiner
Updated January 8, 2025
