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Feb 14 2020

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Job Description of an Insurance Claims Specialist

Learn about the education and preparation needed to become an insurance claims specialist. Get a quick view of the requirements as well as details about training, job duties, and licensure to find out if this is the career for you.

Insurance claims specialists work in a variety of industries reviewing insurance claims. The job growth outlook for these positions is slower than the job market as a whole. The average annual salary is about $64,000.

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Essential Information

Insurance claims specialists, also referred to as claims examiners, or claims investigators are responsible for reviewing a client’s claim in order to determine whether or not they are covered under a policy and to evaluate the extent of a settlement that the insurance company must pay. According to the U.S. Bureau of Labor Statistics (BLS), education and training requirements vary by employer and by state.

Source: *U.S. Bureau of Labor Statistics.

Educational Requirements

Education requirements for insurance claims specialists vary depending on the employer. There is no minimum required education for an insurance claims specialist, and in some cases a high school diploma may be sufficient. However, according to the BLS, employers generally prefer to hire college graduates or those who already have significant experience in the insurance industry (www.bls.gov). One reason that continuing education is useful, the BLS explains, is that federal and state laws affect policies, particularly as they apply to new drug and auto industry regulations. Undergraduate and graduate degree programs in insurance and risk management are available via on-campus and distance-learning options.

Other Requirements

The BLS maintains that licensing requirements for insurance claims specialists vary by state. Some states have few or no requirements for claims examiners, while others have specific licensing requirements. Common requirements include completion of pre-licensing training courses and passing a licensing exam. Some states require insurance companies to be licensed, and allow claims specialists to work under the firm’s license rather than requiring individuals to be licensed. Prospective insurance claims specialists should research their state’s licensing requirements to determine local regulations.

Job Duties of an Insurance Claims Specialist

An insurance claims specialist or claims examiner is responsible for reviewing insurance claims after they are submitted to make sure that proper filing procedures have been followed. Claims specialists may also assist insurance adjusters with complicated or unusual claims. According to the BLS, most insurance claims specialists work full-time outside of the office.

Insurance claims specialists may work in a variety of industries, including auto, property and life insurance. Many claims specialists work for health insurance companies, ensuring that the costs of a particular treatment are reasonable depending on the diagnosis a patient received. In such a case, a claims specialist may consider common treatments, expected hospital stay and disability time. Depending on their findings, claims specialists have the power to approve or deny claims, or to forward them to claim investigators for further review.

An insurance claims specialist’s primary duty is to examine complex or unusual claims to determine whether they may be covered. Other duties include authorizing claim payment, setting reserves on payment, ensuring timely disbursement of funds to clients, coordinating or conducting investigations on insurance claims, identifying claims with possible recovery from third parties, and consulting with attorneys, doctors and agents in regards to the disposition of complex claims.

Career Outlook

The U.S. Bureau of Labor Statistics (BLS) states that the mean salary for claims examiners in May 2015 was $64,300. Most people in the insurance claims specialist occupation earned between $37,880 and $94,190 in 2015, and the profession was expected to see a 3% increase in job growth between the years of 2014 and 2024, the BLS indicates.

In the process of investigating a claim, insurance claims specialists often act as liaisons between legal professionals and the client, manage claim disbursements and research the cost of health treatments. Educational requirements vary by employer and may include a high school diploma or the completion of a postsecondary or degree program, along with prior work experience. Licensing varies by state and may include educational requirements as well as passing an exam.

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