Claims Examiner Job Description

Finding qualified, reliable individuals to join your staff is an essential step in growing your business. We’re here to make the hiring process as easy as possible for you. In this guide, we’ll cover all of the following:


WHAT TO INCLUDE IN A JOB DESCRIPTION

A good job description should include a company overview and job overview, as well as an explanation of the associated responsibilities, skills & qualifications, and work environment. Below are some general guidelines for writing each of these sections effectively.

1. COMPANY OVERVIEW

Providing an accurate, concise description of your business is a great way to attract the right employees. Think of this section as an advertisement for your company -- why should prospective employees want to join your team?

Some useful things to include here are:

  • Core company values
  • Mission statement
  • Brief history of your organization
  • Anticipated growth
  • Business goals

 

2. JOB OVERVIEW

In a few sentences, describe the purpose, importance, and fundamental qualities of the position being offered. No need to be too specific or comprehensive here -- the idea is to provide a zoomed-out image of the role the applicant would be filling in your company.

3. RESPONSIBILITIES

This is where you’ll outline the specific day-to-day responsibilities of the job. Bullet-point format is typically the most practical way to present this information.

4. NECESSARY SKILLS & QUALIFICATIONS

List in bulleted format the skills & qualifications that are absolutely essential to this position. Consider as many specific conditions of the job as possible in order to create a complete list of qualifications an applicant must have in order to succeed.

5. PREFERRED SKILLS & QUALIFICATIONS

List in bulleted format the skills & qualifications that are not essential, but would make an applicant more eligible for the position being offered.

6. WORK ENVIRONMENT

Describe the environment in which the applicant would be spending most of their time. In this description, include information about:

  • Company culture
  • Pace of work
  • Amount of collaborative vs. independent activity
  • Who the employee will report to (or vice versa)

Claims Examiner Job Description

Below is our claims examiner job description. You can post it as-is to an online job board like ZipRecruiter, or download and customize it to match the unique aspects of your business. Keep in mind that adding a custom company overview and description of the work environment (outlined above) will help you draw in the right applicants.

Claims Examiner Job Description 

Job Overview:

Our company’s claims examiners accurately assess submitted medical claims while providing a high level of customer service. Examiners are responsible for making coverage determinations, examining and resolving customer’s claims, and properly documenting their decisions. As a health insurance provider known for customer satisfaction, we need claims examiners who are committed to providing a high level of service during every interaction.

Responsibilities:

  • Determining medical claim coverage based on health insurance policy provisions
  • Collecting and reviewing all data relevant to claims (e.g., from medical documents, policyholders’ statements, medical providers’ statements, etc.)
  • Establishing and documenting proof of loss for valid claims
  • Initiating investigations of any questionable claims
  • Approving and denying claims appropriately, and pay any due compensation
  • Providing excellent customer service during all interactions with policyholders
  • Completing all necessary reports, forms, and logs accurately
  • Ensuring compliance with all applicable laws and regulations
  • Maintaining policyholder confidentiality

Necessary Skills & Qualifications:

  • 1+ years of experience as a claims examiner
  • General familiarity with medical terminology, procedures, and coding
  • Good attention to detail
  • Commitment to providing a high level of customer service
  • High school diploma or equivalent

Preferred Skills & Qualifications:

  • Bachelor’s degree in a medical-related field
  • ALCH or FLHC recognition from the International Claims Association
  • 2+ years of experience as a claims examiner
  • Experience in other customer service roles
  • Bilingual in English and another language
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3 STEPS TO TAKE WHEN HIRING EMPLOYEES

ENSURE LEGAL COMPLIANCE

Hiring employees can be an intimidating and time-consuming process, but it doesn’t have to be. We’ve created a hiring compliance checklist to help you get over the legal hurdles with ease. From obtaining an Employer Identification Number (EIN) to confirming work eligibility, our guide covers everything you need to know.

SET UP PAYROLL

Even if your business only has a few employees, setting up a payroll service can save you time for running your business and also ensure that your company is compliant with important federal requirements, such as employee withholding.

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We recommend Gusto, a user-friendly payroll platform for small businesses. Try out their services and get one month free.

Sign up now

ACQUIRE WORKERS' COMP INSURANCE

Workers’ compensation insurance provides financial and legal protection for your business and its employees.

Whether or not you need workers’ comp insurance for your company depends on the nature of the job, the employer-employee relationship, and the unique regulations of your state.

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Find out how much the right insurance will cost you.

GET A QUOTE