Claims Adjusters, Examiners, and Investigators
What is a Claims Adjusters, Examiners, and Investigators?
Claims Adjusters, Examiners, and Investigators play a crucial role in the insurance industry by assessing and evaluating claims made by policyholders. They are responsible for determining the validity of claims and the amount of compensation to be awarded. This role involves a combination of investigating claims, interviewing relevant parties, collecting evidence, and reviewing policies to ensure that claims are handled fairly and according to the terms of the insurance policy.
Claims Adjusters typically work for insurance companies, where they investigate insurance claims, evaluate the damage, and determine the payment amount. They gather information by talking to claimants, witnesses, and experts, as well as reviewing documents and reports. Their goal is to arrive at a settlement that aligns with the company’s policies and guidelines.
Claims Examiners, on the other hand, are often responsible for reviewing the decisions made by claims adjusters. They analyze claims, examine the evidence presented, and ensure that claims are processed correctly and in compliance with legal and company regulations. Examiners may also suggest changes or improvements in processes for efficiency and compliance.
Investigators, sometimes referred to as claims investigators, delve deeper into dubious or complex claims. They might conduct background checks, surveillance, or take legal action when fraud is suspected. Their primary objective is to uncover fraudulent activities and protect the insurance company's interests while maintaining ethical standards.
Overall, the careers of Claims Adjusters, Examiners, and Investigators require a balance of analytical skills, communication abilities, and a strong understanding of insurance principles and laws. They contribute significantly to the integrity of the insurance system by ensuring that claims are settled fairly and accurately.
Tasks
- Examine claims forms and other records to determine insurance coverage.
- Analyze information gathered by investigation and report findings and recommendations.
- Pay and process claims within designated authority level.
- 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.
- 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.
Technology Skills
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Data base user interface and query software
- Claims processing administration and management software
- Microsoft Access
- Tropics Claims Reserve Management
- Xactware Xactimate
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Video conferencing software
- Zoom
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Document management software
- Datanex ClaimTrac
- Document management system software
- Hyland OnBase Enterprise Content Management
- InSystems Calligo Document Management System
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Expert system software
- Axonwave Fraud and Abuse Management System
- Bill review software
- LexisNexis RiskWise
- StrataCare StrataWare eReview
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Computer aided design CAD software
- 4n6xprt Systems StiffCalcs
- ARSoftware WinSMAC
- PhotoModeler
- Visual Statement Investigator Suite
Tools Used
- Portable data input terminals
- Automotive computer systems
- Theodolites
- Personal digital assistant PDAs or organizers
- Measuring wheels for distance
Knowledge
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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.
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English Language
Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
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Administrative
Knowledge of administrative and office procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and workplace terminology.
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Mathematics
Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
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Computers and Electronics
Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
Skills
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Reading Comprehension
Understanding written sentences and paragraphs in work-related documents.
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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.
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Critical Thinking
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
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Speaking
Talking to others to convey information effectively.
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Judgment and Decision Making
Considering the relative costs and benefits of potential actions to choose the most appropriate one.
Abilities
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Written Comprehension
The ability to read and understand information and ideas presented in writing.
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Oral Comprehension
The ability to listen to and understand information and ideas presented through spoken words and sentences.
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Oral Expression
The ability to communicate information and ideas in speaking so others will understand.
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Deductive Reasoning
The ability to apply general rules to specific problems to produce answers that make sense.
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Inductive Reasoning
The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
Education
How much education does a new hire need to perform a job in this occupation?
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Bachelor's degree
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High school diploma or equivalent
or: GED, High School Equivalency Certificate
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Some college, no degree
Work Activities
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Working with Computers
Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
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Communicating with People Outside the Organization
Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail.
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Getting Information
Observing, receiving, and otherwise obtaining information from all relevant sources.
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Identifying Objects, Actions, and Events
Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
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Making Decisions and Solving Problems
Analyzing information and evaluating results to choose the best solution and solve problems.
Detailed Work Activities
- Calculate data to inform organizational operations.
- Investigate legal issues.
- Negotiate agreements to resolve disputes.
- Pay charges, fees, or taxes.
- Prepare legal or investigatory documentation.
Work Interests
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Conventional
Work involves following procedures and regulations to organize information or data, typically in a business setting. Conventional occupations are often associated with office work, accounting, mathematics/statistics, information technology, finance, or human resources.
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Enterprising
Work involves managing, negotiating, marketing, or selling, typically in a business setting, or leading or advising people in political and legal situations. Enterprising occupations are often associated with business initiatives, sales, marketing/advertising, finance, management/administration, professional advising, public speaking, politics, or law.
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Investigative
Work involves studying and researching non-living objects, living organisms, disease or other forms of impairment, or human behavior. Investigative occupations are often associated with physical, life, medical, or social sciences, and can be found in the fields of humanities, mathematics/statistics, information technology, or health care service.
Job Outlook
Projected salary and job growth
$47390.0 - $105440.0
New job opportunities are less likely in the future. : Below Average
Assessment
Related assessments and tests
No assessment available.