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Claims Examiners, Property and Casualty Insurance
SOC Code: 13-1031.01

Review settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures. Report overpayments, underpayments, and other irregularities. Confer with legal counsel on claims requiring litigation.

Sample of reported job titles: Claims Adjuster, Claims Analyst, Claims Examiner, Claims Manager, Claims Representative, Claims Specialist, Claims Supervisor, Corporate Claims Examiner, Customer Care Specialist, Home Office Claim Specialist

Tasks

  • Investigate, evaluate, and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
  • Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
  • Resolve complex, severe exposure claims, using high service oriented file handling.
  • Pay and process claims within designated authority level.
  • Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
  • Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
  • Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
  • Confer with legal counsel on claims requiring litigation.
  • Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
  • Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
  • Present cases and participate in their discussion at claim committee meetings.
  • Supervise claims adjusters to ensure that adjusters have followed proper methods.
  • Conduct detailed bill reviews to implement sound litigation management and expense control.
  • Report overpayments, underpayments, and other irregularities.
  • Communicate with reinsurance brokers to obtain information necessary for processing claims.
  • Prepare reports to be submitted to company's data processing department.

Technology Skills

  • Access software - CCC EZNet electronic communications network; CSC Automated Work Distributor AWD
  • Analytical or scientific software - Insurance claims fraud detection software; Magnify Predictive Targeting System
  • Data base reporting software - Corporate Systems ClaimsPro
  • Data base user interface and query software - Claims processing administration and management software; Fair Isaac Claims Advisor; Tropics Claims Reserve Management
  • Desktop publishing software - Microsoft Publisher
  • Document management software - Agency Management Systems AMS 360; BCCORP W5 for Adjusters; Document management system software; InSystems Calligo Document Management System (see all 19 examples)
  • Enterprise resource planning ERP software - CCC Pathways Appraisal Quality Solution
  • Expert system software - Axonwave Fraud and Abuse Management System; Bill review software; LexisNexis RiskWise; StrataCare StrataWare eReview (see all 12 examples)
  • Interactive voice response software - Computerized voice stress analyzer CVSA software
  • Medical software - Healthcare common procedure coding system HCPCS ; Medical condition coding software ; Medical procedure coding software
  • Office suite software - Microsoft Office
  • Presentation software - Microsoft PowerPoint
  • Spreadsheet software - Microsoft Excel
  • Word processing software - Microsoft Word

Tools Used

  • Desktop computers
  • Notebook computers
  • Personal computers
  • Personal digital assistant PDAs or organizers - Personal digital assistants PDA
  • Scanners
  • Tablet computers

Knowledge

  • Customer and Personal Service - Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
  • English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
  • Law and Government - Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
  • Administration and Management - Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.

Skills

  • Reading Comprehension - Understanding written sentences and paragraphs in work related documents.
  • Writing - Communicating effectively in writing as appropriate for the needs of the audience.
  • Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
  • Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
  • Speaking - Talking to others to convey information effectively.
  • Negotiation - Bringing others together and trying to reconcile differences.
  • Judgment and Decision Making - Considering the relative costs and benefits of potential actions to choose the most appropriate one.
  • Complex Problem Solving - Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
  • Monitoring - Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
  • Social Perceptiveness - Being aware of others' reactions and understanding why they react as they do.
  • Active Learning - Understanding the implications of new information for both current and future problem-solving and decision-making.
  • Coordination - Adjusting actions in relation to others' actions.
  • Service Orientation - Actively looking for ways to help people.
  • Persuasion - Persuading others to change their minds or behavior.
  • Time Management - Managing one's own time and the time of others.

Abilities

  • Oral Comprehension - The ability to listen to and understand information and ideas presented through spoken words and sentences.
  • Written Comprehension - The ability to read and understand information and ideas presented in writing.
  • Deductive Reasoning - The ability to apply general rules to specific problems to produce answers that make sense.
  • Oral Expression - The ability to communicate information and ideas in speaking so others will understand.
  • Problem Sensitivity - The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
  • Inductive Reasoning - The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
  • Speech Clarity - The ability to speak clearly so others can understand you.
  • Speech Recognition - The ability to identify and understand the speech of another person.
  • Written Expression - The ability to communicate information and ideas in writing so others will understand.
  • Information Ordering - The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).
  • Near Vision - The ability to see details at close range (within a few feet of the observer).
  • Category Flexibility - The ability to generate or use different sets of rules for combining or grouping things in different ways.
  • Mathematical Reasoning - The ability to choose the right mathematical methods or formulas to solve a problem.
  • Selective Attention - The ability to concentrate on a task over a period of time without being distracted.

Interests

  • Interest code: CE
    • Conventional - Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow.
    • Enterprising - Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business.

Work Context

  • Electronic Mail - 99% responded “Every day.”
  • Telephone - 100% responded “Every day.”
  • Letters and Memos - 95% responded “Every day.”
  • Importance of Being Exact or Accurate - 80% responded “Extremely important.”
  • Contact With Others - 75% responded “Constant contact with others.”
  • Frequency of Decision Making - 75% responded “Every day.”
  • Impact of Decisions on Co-workers or Company Results - 71% responded “Very important results.”
  • Duration of Typical Work Week - 86% responded “More than 40 hours.”
  • Indoors, Environmentally Controlled - 88% responded “Every day.”
  • Spend Time Sitting - 62% responded “Continually or almost continually.”
  • Face-to-Face Discussions - 61% responded “Every day.”
  • Frequency of Conflict Situations - 67% responded “Every day.”
  • Work With Work Group or Team - 57% responded “Extremely important.”
  • Deal With External Customers - 70% responded “Extremely important.”
  • Freedom to Make Decisions - 37% responded “A lot of freedom.”
  • Importance of Repeating Same Tasks - 56% responded “Very important.”
  • Spend Time Making Repetitive Motions - 59% responded “Continually or almost continually.”
  • Time Pressure - 18% responded “Once a week or more but not every day.”
  • Degree of Automation - 48% responded “Highly automated.”
  • Level of Competition - 44% responded “Extremely competitive.”
  • Structured versus Unstructured Work - 41% responded “A lot of freedom.”
  • Coordinate or Lead Others - 40% responded “Extremely important.”
  • Sounds, Noise Levels Are Distracting or Uncomfortable - 29% responded “Every day.”
  • Deal With Unpleasant or Angry People
  • Physical Proximity - 43% responded “Slightly close (e.g., shared office).”
  • Responsibility for Outcomes and Results - 31% responded “High responsibility.”

Education

Percentage of RespondentsEducation Level Required
69%Bachelor's degree
12%High school diploma or equivalent
8%Some college, no degree

Work Styles

  • Integrity - Job requires being honest and ethical.
  • Dependability - Job requires being reliable, responsible, and dependable, and fulfilling obligations.
  • Attention to Detail - Job requires being careful about detail and thorough in completing work tasks.
  • Stress Tolerance - Job requires accepting criticism and dealing calmly and effectively with high stress situations.
  • Self Control - Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.
  • Cooperation - Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
  • Independence - Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.
  • Persistence - Job requires persistence in the face of obstacles.
  • Adaptability/Flexibility - Job requires being open to change (positive or negative) and to considerable variety in the workplace.
  • Analytical Thinking - Job requires analyzing information and using logic to address work-related issues and problems.
  • Initiative - Job requires a willingness to take on responsibilities and challenges.
  • Achievement/Effort - Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks.
  • Concern for Others - Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job.
  • Leadership - Job requires a willingness to lead, take charge, and offer opinions and direction.
  • Innovation - Job requires creativity and alternative thinking to develop new ideas for and answers to work-related problems.
  • Social Orientation - Job requires preferring to work with others rather than alone, and being personally connected with others on the job.

Work Values

  • Independence - Occupations that satisfy this work value allow employees to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy.
  • Support - Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical.
  • Working Conditions - Occupations that satisfy this work value offer job security and good working conditions. Corresponding needs are Activity, Compensation, Independence, Security, Variety and Working Conditions.

Wages & Trends

  • Median wages (2017)
    • $31.20 hourly, $64,900 annual
  • Employment (2016)
    • 311,000 employees
  • Projected growth (2016-2026)
    • Little or no change (-1% to 1%)
  • Projected job openings (2016-2026)
    • 24,500

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