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Claims Adjusters, Examiners, and Investigators

Claims Adjusters, Examiners, and Investigators

Overview
Job Zone Four: Considerable Preparation Needed
Experience

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

Most of these occupations require a four-year bachelor's degree, but some do not.

Job Training

Employees in these occupations usually need several years of work-related experience, on-the-job training, and/or vocational training.

Examples

Many of these occupations involve coordinating, supervising, managing, or training others. Examples include real estate brokers, sales managers, database administrators, graphic designers, chemists, art directors, and cost estimators.

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.

Salary Salary

Salary at 10th Percentile: $41K
Salary at 25th Percentile: $52K
Median Salary: $68K
Salary at 75th Percentile: $85K
Salary at 90th Percentile: $103K

Demand
Career Demand by State Career Demand by State Legend
Core Tasks

Analyze information gathered by investigation and report findings and recommendations.

Examine claims forms and other records to determine insurance coverage.

Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.

Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.

Investigate and assess damage to property and create or review property damage estimates.

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.

Supervise claims adjusters to ensure that adjusters have followed proper methods.

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.

Collect evidence to support contested claims in court.

Refer questionable claims to investigator or claims adjuster for investigation or settlement.

Confer with legal counsel on claims requiring litigation.

Conduct detailed bill reviews to implement sound litigation management and expense control.

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.

Examine titles to property to determine validity and act as company agent in transactions with property owners.

Report overpayments, underpayments, and other irregularities.

Present cases and participate in their discussion at claim committee meetings.

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.

Technology Skills
Technology
Example
Hot Technology
Access software
CSC Automated Work Distributor AWD
Analytical or scientific software
Insurance claims fraud detection software
Computer aided design CAD software
Visual Statement Investigator Suite
Data base reporting software
Corporate Systems ClaimsPro
Data base user interface and query software
Tropics Claims Reserve Management
Desktop publishing software
Microsoft Publisher
Document management software
Bramerhill ClaimsTech
Enterprise resource planning ERP software
CCC Pathways Appraisal Quality Solution
Expert system software
StrataCare StrataWare eReview
Financial analysis software
Turtle Creek Software Goldenseal Architect
Information retrieval or search software
CGI-AMS BureauLink Enterprise
Interactive voice response software
Computerized voice stress analyzer CVSA software
Medical software
Healthcare common procedure coding system HCPCS
Office suite software
Microsoft Office
Presentation software
Microsoft PowerPoint
Spreadsheet software
Microsoft Excel
Word processing software
Microsoft Word
Tools Used
Tool
Example
Computer Equipment and Accessories
Mobile wireless handheld communication devices
Measuring and observing and testing instruments
Total stations
Transportation components and systems
Event data recorders
Top 10 Knowledge Required
Customer and Personal Service
87%
Importance

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
86%
Importance

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
72%
Importance

Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.

Clerical
67%
Importance

Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.

Mathematics
66%
Importance

Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.

Administration and Management
63%
Importance

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.

Computers and Electronics
60%
Importance

Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.

Education and Training
55%
Importance

Knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects.

Psychology
55%
Importance

Knowledge of human behavior and performance; individual differences in ability, personality, and interests; learning and motivation; psychological research methods; and the assessment and treatment of behavioral and affective disorders.

Communications and Media
53%
Importance

Knowledge of media production, communication, and dissemination techniques and methods. This includes alternative ways to inform and entertain via written, oral, and visual media.

Top 10 Skills
Critical Thinking
78%
Importance

Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.

Reading Comprehension
78%
Importance

Understanding written sentences and paragraphs in work related documents.

Active Listening
77%
Importance

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.

Speaking
77%
Importance

Talking to others to convey information effectively.

Negotiation
74%
Importance

Bringing others together and trying to reconcile differences.

Writing
74%
Importance

Communicating effectively in writing as appropriate for the needs of the audience.

Active Learning
67%
Importance

Understanding the implications of new information for both current and future problem-solving and decision-making.

Judgment and Decision Making
67%
Importance

Considering the relative costs and benefits of potential actions to choose the most appropriate one.

Complex Problem Solving
65%
Importance

Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Social Perceptiveness
65%
Importance

Being aware of others' reactions and understanding why they react as they do.

Top 10 Abilities
Oral Comprehension
80%
Importance

The ability to listen to and understand information and ideas presented through spoken words and sentences.

Written Comprehension
80%
Importance

The ability to read and understand information and ideas presented in writing.

Deductive Reasoning
79%
Importance

The ability to apply general rules to specific problems to produce answers that make sense.

Oral Expression
79%
Importance

The ability to communicate information and ideas in speaking so others will understand.

Inductive Reasoning
77%
Importance

The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).

Speech Clarity
75%
Importance

The ability to speak clearly so others can understand you.

Near Vision
73%
Importance

The ability to see details at close range (within a few feet of the observer).

Problem Sensitivity
73%
Importance

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.

Speech Recognition
73%
Importance

The ability to identify and understand the speech of another person.

Written Expression
73%
Importance

The ability to communicate information and ideas in writing so others will understand.

Top 10 Work Activities
Interacting With Computers
92%
Importance

Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.

Communicating with Supervisors, Peers, or Subordinates
90%
Importance

Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.

Getting Information
90%
Importance

Observing, receiving, and otherwise obtaining information from all relevant sources.

Making Decisions and Solving Problems
90%
Importance

Analyzing information and evaluating results to choose the best solution and solve problems.

Resolving Conflicts and Negotiating with Others
90%
Importance

Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.

Identifying Objects, Actions, and Events
88%
Importance

Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.

Documenting/Recording Information
86%
Importance

Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.

Processing Information
86%
Importance

Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.

Communicating with Persons Outside Organization
85%
Importance

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.

Evaluating Information to Determine Compliance with Standards
85%
Importance

Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.

Detailed Work Activities

Calculate data to inform organizational operations.

Investigate legal issues.

Prepare legal or investigatory documentation.

Estimate costs of goods or services.

Appraise property values.

Interview witnesses, suspects, or claimants.

Negotiate agreements to resolve disputes.

Implement financial decisions.

Advise others on financial matters.

Pay charges, fees, or taxes.

Verify accuracy of records.

Maintain data in information systems or databases.

Report information to managers or other personnel.

Collect evidence for legal proceedings.

Meet with individuals involved in legal processes to provide information and clarify issues.

Prepare financial documents.

Present business-related information to audiences.

Supervise employees.

Examine financial records.

Confer with others about financial matters.

Prepare operational reports.

Gather financial records.

Verify application data to determine program eligibility.

Advise others on legal or regulatory compliance matters.

Majors
Major
Health/Medical Claims Examiner
Insurance
Interests
Conventional
96%
Importance

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
77%
Importance

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.

Investigative
43%
Importance

Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally.

Realistic
39%
Importance

Realistic occupations frequently involve work activities that include practical, hands-on problems and solutions. They often deal with plants, animals, and real-world materials like wood, tools, and machinery. Many of the occupations require working outside, and do not involve a lot of paperwork or working closely with others.

Social
39%
Importance

Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.

Artistic
19%
Importance

Artistic occupations frequently involve working with forms, designs and patterns. They often require self-expression and the work can be done without following a clear set of rules.

Top 10 Work Styles
Integrity
97%
Importance

Job requires being honest and ethical.

Dependability
94%
Importance

Job requires being reliable, responsible, and dependable, and fulfilling obligations.

Attention to Detail
93%
Importance

Job requires being careful about detail and thorough in completing work tasks.

Self Control
92%
Importance

Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.

Stress Tolerance
92%
Importance

Job requires accepting criticism and dealing calmly and effectively with high stress situations.

Independence
89%
Importance

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.

Adaptability/Flexibility
88%
Importance

Job requires being open to change (positive or negative) and to considerable variety in the workplace.

Initiative
88%
Importance

Job requires a willingness to take on responsibilities and challenges.

Persistence
87%
Importance

Job requires persistence in the face of obstacles.

Achievement/Effort
86%
Importance

Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks.

Work Values
Support
69%
Importance

Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical.

Independence
67%
Importance

Occupations that satisfy this work value allow employees to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy.

Working Conditions
66%
Importance

Occupations that satisfy this work value offer job security and good working conditions. Corresponding needs are Activity, Compensation, Independence, Security, Variety and Working Conditions.

Relationships
65%
Importance

Occupations that satisfy this work value allow employees to provide service to others and work with co-workers in a friendly non-competitive environment. Corresponding needs are Co-workers, Moral Values and Social Service.

Achievement
60%
Importance

Occupations that satisfy this work value are results oriented and allow employees to use their strongest abilities, giving them a feeling of accomplishment. Corresponding needs are Ability Utilization and Achievement.

Recognition
55%
Importance

Occupations that satisfy this work value offer advancement, potential for leadership, and are often considered prestigious. Corresponding needs are Advancement, Authority, Recognition and Social Status.