Claims Adjusters, Examiners, and Investigator Review settled claims to determine that payments and settlements are made in accordance with company practices and procedures. Confer with legal counsel on claims requiring litigation. May also settle insurance claims.
Claims Adjusters, Examiners, and Investigator is Also Know as
In different settings, Claims Adjusters, Examiners, and Investigator is titled as
- Claims Adjuster
- Claims Analyst
- Claims Examiner
- Claims Representative
- Claims Specialist
- Corporate Claims Examiner
- Field Claims Adjuster
- General Adjuster
- Home Office Claims Specialist
- Litigation Claims Representative
Education and Training of Claims Adjusters, Examiners, and Investigator
Claims Adjusters, Examiners, and Investigator is categorized in Job Zone Four: Considerable Preparation Needed
Experience Required for Claims Adjusters, Examiners, and Investigator
A considerable amount of work-related skill, knowledge, or experience is needed for these occupations. For example, an accountant must complete four years of college and work for several years in accounting to be considered qualified.
Education Required for Claims Adjusters, Examiners, and Investigator
Most of these occupations require a four-year bachelor's degree, but some do not.
Degrees Related to Claims Adjusters, Examiners, and Investigator
- Bachelor in Health/Medical Claims Examiner
- Associate Degree Courses in Health/Medical Claims Examiner
- Masters Degree Courses in Health/Medical Claims Examiner
- Bachelor in Insurance
- Associate Degree Courses in Insurance
- Masters Degree Courses in Insurance
Training Required for Claims Adjusters, Examiners, and Investigator
Employees in these occupations usually need several years of work-related experience, on-the-job training, and/or vocational training.
Related Ocuupations
Some Ocuupations related to Claims Adjusters, Examiners, and Investigator in different industries are
- Insurance Claims and Policy Processing Clerks
- Eligibility Interviewers, Government Programs
- Compensation, Benefits, and Job Analysis Specialists
- Credit Authorizers, Checkers, and Clerks
- Fraud Examiners, Investigators and Analysts
- Compliance Officers
- Insurance Sales Agents
- Insurance Underwriters
- Tax Examiners and Collectors, and Revenue Agents
- Appraisers and Assessors of Real Estate
- Lawyers
- Administrative Law Judges, Adjudicators, and Hearing Officers
- Customer Service Representatives
- Title Examiners, Abstractors, and Searchers
- Private Detectives and Investigators
- Paralegals and Legal Assistants
- Government Property Inspectors and Investigators
- Legal Secretaries and Administrative Assistants
- Arbitrators, Mediators, and Conciliators
- Billing and Posting Clerks
What Do Claims Adjusters, Examiners, and Investigator do?
- Examine claims forms and other records to determine insurance coverage.
- Analyze information gathered by investigation and report findings and recommendations.
- Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.
- Investigate and assess damage to property and create or review property damage estimates.
- Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
- Interview or correspond with claimants, witnesses, police, physicians, or other relevant parties to determine claim settlement, denial, or review.
- 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.
- Refer questionable claims to investigator or claims adjuster for investigation or settlement.
- Collect evidence to support contested claims in court.
- 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.
- Examine titles to property to determine validity and act as company agent in transactions with property owners.
- 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.
- Obtain credit information from banks and other credit services.
- Attend mediations or trials.
- Communicate with former associates to verify employment record or to obtain background information regarding persons or businesses applying for credit.
- Negotiate claim settlements or recommend litigation when settlement cannot be negotiated.
Qualities of Good Claims Adjusters, Examiners, and Investigator
- Written Comprehension: The ability to read and understand information and ideas presented in writing.
- Oral Expression: The ability to communicate information and ideas in speaking so others will understand.
- Oral Comprehension: The ability to listen to and understand information and ideas presented through spoken words and sentences.
- Inductive Reasoning: The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
- Deductive Reasoning: The ability to apply general rules to specific problems to produce answers that make sense.
- Written Expression: The ability to communicate information and ideas in writing so others will understand.
- Near Vision: The ability to see details at close range (within a few feet of the observer).
- Speech Clarity: The ability to speak clearly so others can understand you.
- 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 that there is a problem.
- 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).
- Speech Recognition: The ability to identify and understand the speech of another person.
- Category Flexibility: The ability to generate or use different sets of rules for combining or grouping things in different ways.
- Flexibility of Closure: The ability to identify or detect a known pattern (a figure, object, word, or sound) that is hidden in other distracting material.
- Mathematical Reasoning: The ability to choose the right mathematical methods or formulas to solve a problem.
- Number Facility: The ability to add, subtract, multiply, or divide quickly and correctly.
- Speed of Closure: The ability to quickly make sense of, combine, and organize information into meaningful patterns.
- Perceptual Speed: The ability to quickly and accurately compare similarities and differences among sets of letters, numbers, objects, pictures, or patterns. The things to be compared may be presented at the same time or one after the other. This ability also includes comparing a presented object with a remembered object.
- Selective Attention: The ability to concentrate on a task over a period of time without being distracted.
- Far Vision: The ability to see details at a distance.
- Fluency of Ideas: The ability to come up with a number of ideas about a topic (the number of ideas is important, not their quality, correctness, or creativity).
- Time Sharing: The ability to shift back and forth between two or more activities or sources of information (such as speech, sounds, touch, or other sources).
- Memorization: The ability to remember information such as words, numbers, pictures, and procedures.
- Originality: The ability to come up with unusual or clever ideas about a given topic or situation, or to develop creative ways to solve a problem.
- Visualization: The ability to imagine how something will look after it is moved around or when its parts are moved or rearranged.
- Auditory Attention: The ability to focus on a single source of sound in the presence of other distracting sounds.
- Trunk Strength: The ability to use your abdominal and lower back muscles to support part of the body repeatedly or continuously over time without "giving out" or fatiguing.
- Visual Color Discrimination: The ability to match or detect differences between colors, including shades of color and brightness.
- Wrist-Finger Speed: The ability to make fast, simple, repeated movements of the fingers, hands, and wrists.
- Hearing Sensitivity: The ability to detect or tell the differences between sounds that vary in pitch and loudness.
- Arm-Hand Steadiness: The ability to keep your hand and arm steady while moving your arm or while holding your arm and hand in one position.
- Manual Dexterity: The ability to quickly move your hand, your hand together with your arm, or your two hands to grasp, manipulate, or assemble objects.
- Finger Dexterity: The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects.
- Dynamic Strength: The ability to exert muscle force repeatedly or continuously over time. This involves muscular endurance and resistance to muscle fatigue.
- Control Precision: The ability to quickly and repeatedly adjust the controls of a machine or a vehicle to exact positions.
- Depth Perception: The ability to judge which of several objects is closer or farther away from you, or to judge the distance between you and an object.
- Spatial Orientation: The ability to know your location in relation to the environment or to know where other objects are in relation to you.
- Speed of Limb Movement: The ability to quickly move the arms and legs.
- Response Orientation: The ability to choose quickly between two or more movements in response to two or more different signals (lights, sounds, pictures). It includes the speed with which the correct response is started with the hand, foot, or other body part.
- Sound Localization: The ability to tell the direction from which a sound originated.
- Glare Sensitivity: The ability to see objects in the presence of a glare or bright lighting.
- Peripheral Vision: The ability to see objects or movement of objects to one's side when the eyes are looking ahead.
- Night Vision: The ability to see under low-light conditions.
- Multilimb Coordination: The ability to coordinate two or more limbs (for example, two arms, two legs, or one leg and one arm) while sitting, standing, or lying down. It does not involve performing the activities while the whole body is in motion.
- Rate Control: The ability to time your movements or the movement of a piece of equipment in anticipation of changes in the speed and/or direction of a moving object or scene.
- Gross Body Equilibrium: The ability to keep or regain your body balance or stay upright when in an unstable position.
- Gross Body Coordination: The ability to coordinate the movement of your arms, legs, and torso together when the whole body is in motion.
- Dynamic Flexibility: The ability to quickly and repeatedly bend, stretch, twist, or reach out with your body, arms, and/or legs.
- Extent Flexibility: The ability to bend, stretch, twist, or reach with your body, arms, and/or legs.
- Stamina: The ability to exert yourself physically over long periods of time without getting winded or out of breath.
- Reaction Time: The ability to quickly respond (with the hand, finger, or foot) to a signal (sound, light, picture) when it appears.
- Explosive Strength: The ability to use short bursts of muscle force to propel oneself (as in jumping or sprinting), or to throw an object.
- Static Strength: The ability to exert maximum muscle force to lift, push, pull, or carry objects.
Tools Used by Claims Adjusters, Examiners, and Investigator
- Data collectors
- Desktop computers
- Event data recorders
- Field computers
- Handheld computers
- Measure markers
- Mobile wireless handheld communication devices
- Notebook computers
- Personal computers
- Personal digital assistants PDA
- Scanners
- Tablet computers
- Total stations
Technology Skills required for Claims Adjusters, Examiners, and Investigator
- 4n6xprt Systems StiffCalcs
- ADP software
- Agency Management Systems AMS 360
- Apple Safari
- ARSoftware WinSMAC
- AutoClaims Direct DirectLink
- Automatic Data Processing Autosource
- Automatic Data Processing Claims Manager & Dispatch
- Automatic Data Processing Estimating
- Axonwave Fraud and Abuse Management System
- BCCORP Burkitt W5
- BCCORP W5 for Adjusters
- Bill review software
- Bramerhill ClaimsTech
- Bridium Claims 3
- Brightwork Alyce Claims Systems
- Business software applications
- CAD Zone Insurance
- Captiva InputAccel
- Castek Insure3 Claims
- CCC EZNet electronic communications network
- CCC GuidePost Decision Support
- CCC Pathways Appraisal Quality Solution
- CCC Pathways Image Management Solution
- CCC TL2000 Solution
- CGI INSideOUT
- CGI-AMS BureauLink Enterprise
- Claims processing administration and management software
- Clear Technology Tranzax
- Computerized voice stress analyzer CVSA software
- Corporate Systems ClaimsPro
- Covansys ClaimConnect
- CSC Automated Work Distributor AWD
- CSC Colossus
- CSC Fault Evaluator
- Datanex ClaimTrac
- Document management system software
- Fair Isaac Claims Advisor
- Fair Isaac SmartAdvisor
- First Notice Systems ClaimCapture
- Healthcare common procedure coding system HCPCS
- Hummingbird Legal Bill Review
- Hyland OnBase Enterprise Content Management
- IBM Fraud and Abuse Management System
- Injury Sciences EDR InSight
- Insurance claims fraud detection software
- InSystems Calligo Document Management System
- ISO ClaimSearch
- ISO NetMap for Claims
- LexisNexis RiskWise
- Magnify Predictive Targeting System
- MapScenes Evidence Recorder
- MapScenes Pro
- Medical condition coding software
- Medical procedure coding software
- Microsoft Access
- Microsoft Excel
- Microsoft Office software
- Microsoft Outlook
- Microsoft PowerPoint
- Microsoft Publisher
- Microsoft Word
- Mozilla Firefox
- PhotoModeler
- Property damage, bodily injury, and liability estimation software
- QwikQuote software
- Simsol for Adjusters
- StrataCare StrataWare eReview
- Tropics Claims Reserve Management
- Turtle Creek Software Goldenseal Architect
- Visual Statement Investigator Suite
- Xactware Xactimate
- Zoom