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Title
Text copied to clipboard!Claims Examiner
Description
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We are looking for a detail-oriented and analytical Claims Examiner to join our insurance operations team. The ideal candidate will be responsible for reviewing, evaluating, and processing insurance claims to determine the extent of the company’s liability. This role requires strong investigative skills, a deep understanding of insurance policies, and the ability to communicate effectively with claimants, medical professionals, and legal representatives.
As a Claims Examiner, you will analyze claim forms, medical records, and other supporting documents to ensure claims are valid and comply with policy terms. You will work closely with adjusters, underwriters, and legal teams to resolve complex claims and ensure timely and accurate claim settlements. You will also be responsible for identifying potential fraud and recommending appropriate actions.
This position demands a high level of integrity, discretion, and the ability to make sound judgments under pressure. You must be comfortable working with data and using claims management software to track and document claim progress. A successful Claims Examiner is organized, efficient, and committed to delivering excellent customer service while protecting the financial interests of the company.
Key aspects of the role include maintaining compliance with regulatory requirements, staying updated on industry trends, and contributing to process improvements within the claims department. If you have a background in insurance, healthcare, or legal services and enjoy problem-solving and decision-making, this could be the perfect opportunity for you.
Responsibilities
Text copied to clipboard!- Review and evaluate insurance claims for accuracy and completeness
- Determine coverage and liability based on policy terms
- Communicate with claimants, providers, and legal representatives
- Identify and investigate potential fraudulent claims
- Collaborate with adjusters and underwriters to resolve complex cases
- Ensure claims are processed in a timely and accurate manner
- Maintain detailed records of claim decisions and communications
- Stay current with industry regulations and compliance standards
- Recommend claim approvals or denials based on findings
- Participate in audits and quality assurance reviews
Requirements
Text copied to clipboard!- Bachelor’s degree in insurance, business, or related field
- 2+ years of experience in claims examination or insurance
- Strong analytical and decision-making skills
- Excellent written and verbal communication abilities
- Familiarity with claims management software
- Knowledge of insurance policies and legal terminology
- Attention to detail and high level of accuracy
- Ability to handle confidential information with discretion
- Strong organizational and time management skills
- Ability to work independently and as part of a team
Potential interview questions
Text copied to clipboard!- Do you have experience reviewing insurance claims?
- Are you familiar with claims management systems?
- Can you describe a time you identified a fraudulent claim?
- How do you ensure compliance with insurance regulations?
- What types of insurance claims have you handled?
- How do you prioritize multiple claims with tight deadlines?
- Have you worked with legal teams on claim disputes?
- What strategies do you use to maintain accuracy in documentation?
- Are you comfortable making decisions under pressure?
- What is your experience with medical or legal terminology?
