Medical Claims Examiner
Quick Facts
Median Salary$51,920
Most Common EducationHigh school or GED
Projected 10-Year Growth+5.86%
Assessment MatchTake the Assessment
What They Do
A Medical Claims Examiner evaluates medical insurance claims in accordance with applicable contracts and government regulations. Verifies that medical treatment costs are accurate given a patient's diagnosis. May specialize in specific types of treatments or types of drug claims.
Core Tasks:
- Examine claims forms and other records to determine insurance coverage.
- Analyze information gathered by investigation and report findings and recommendations.
- 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.
- Pay and process claims within designated authority level.
- Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.
- 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.
- 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.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- Confer with legal counsel on claims requiring litigation.
- Refer questionable claims to investigator or claims adjuster for investigation or settlement.
- Collect evidence to support contested claims in court.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
- Present cases and participate in their discussion at claim committee meetings.
- Report overpayments, underpayments, and other irregularities.
- Attend mediations or trials.
What to expect as a Medical Claims Examiner
1Earn a High school or GED Diploma
57% of people achieve this level of education.
2Gain skills and experience
See Medical Claims Examiner related courses on Tallo
3Land a job
102 openings for Medical Claims Examiners
Career Progression
in United States (Nation)
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