CLAIMS EXAMINER SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

The Claims Examiner role demands mastery of Microsoft Office Suite to manage and document claim details efficiently. This position requires extended work hours during peak seasons to meet business needs and maintain client satisfaction. Key responsibilities include drafting precise correspondence for claims processing, passionately delivering superior customer service, and engaging effectively with clients and brokers to optimize claim settlements.

Essential Hard and Soft Skills for a Standout Claims Examiner Resume
  • Insurance Knowledge
  • Legal Compliance
  • Data Analysis
  • Financial Acumen
  • Document Management
  • Microsoft Office Proficiency
  • Claims Processing Software
  • Risk Assessment
  • Report Writing
  • Regulatory Knowledge
  • Communication Skills
  • Problem Solving
  • Customer Service
  • Attention to Detail
  • Negotiation Skills
  • Decision Making
  • Empathy
  • Organizational Skills
  • Teamwork
  • Stress Management

Summary of Claims Examiner Knowledge and Qualifications on Resume

1. BS in Finance with 2 years of Experience

  • College degree or equivalent job experience
  • Should know various property insurance coverages and forms
  • Advanced computer knowledge (Word/Excel/Lotus Notes)
  • Mathematical aptitude, sound organizational skills
  • Attention to detail and accuracy
  • Focus on quality, performance and customer service
  • Professional attitude and strong interpersonal skills
  • Good oral and written communication skills
  • Good presentation skills and ability to prioritize multiple tasks
  • Ability to contribute effectively in a team environment.

2. BS in Business Administration with 3 years of Experience

  • Prior healthcare claims processing experience.
  • Prior Insurance and Billing Experience.
  • Knowledge and experience with ICD/CPT codes.
  • Excellent written and verbal communication skills.
  • Ability to work independently with minimal supervision.
  • Experience handling Homeowners' Property claims from inception to close
  • Experience handling Commercial Property claims
  • Knowledge of PCP, Capitation, Specialty, Ancillary, ER, and Facility claims to process
  • Excellent communication skills both written and verbal
  • CPT and ICD -9 and ICD-10 coding
  • Previous background in claims processing

3. BS in Accounting with 5 years of Experience

  • Proactive, and thorough investigation of every claim
  • Timely in claim handling and adjusting
  • Ability to work independently, strong team player and positive contributor
  • Careful with attention to detail handling claims documentation with electronic notes
  • Appropriate management of claims expenses
  • Timely loss reserving according to client's respective reserve philosophies
  • Focused on dealing with claims properly and economically
  • Professional, paying claims only where insured or insurer is legally liable
  • AHIP certifications
  • Strong in Microsoft Office, Bankers’ BICPS and SHARP administrative systems and other company-sponsored applications.
  • Experience in social work or social casework

4. BS in Economics with 4 years of Experience

  • Level 2 Insurance Adjuster’s License or Level 2 General Insurance License
  • Ability to learn and apply knowledge of policy wordings to accurately process claims
  • Strong analytical and decision-making skills, detail-oriented and well-organized
  • Excellent communication/customer service skills, particularly using the phone
  • Written and verbal fluency in English and an additional language – preferably French, Spanish, Mandarin, or Cantonese
  • Previous experience assessing claims
  • Experience in a customer service role and ability to multi-task
  • Strong interpersonal, and conflict resolution skills
  • Knowledge of medical terminology
  • A criminal record check is a requirement of the position as required by insurance councils for licensing
  • Once fully trained, the work schedule will include some non-business hour shifts (weekend and evening shifts)

5. BS in Risk Management and Insurance with 2 years of Experience

  • Excellent written communication skills
  • Excellent oral negotiation skills and intermediate computer skills
  • Completed one or more CPCU, AEI, or equivalent courses on Legal Principles, Liability Principles or Litigation Management
  • Experience with client/server claims processing systems
  • Proficient in MS Office Suite and able to learn applications quickly
  • Able to consistently live values of valued, effective and trusted
  • A strong customer experience focus
  • A passion for continuous learning and professional achievement
  • Fluency in a non-English language
  • Experience in data analytics

6. BS in Health Administration with 6 years of Experience

  • Have complex claims experience with Medicare Benefits, including fee-for-service Medicare and Medicare Advantage Plans.
  • Experience with Medicaid Benefits, including members that are dually covered by Medicare
  • Knowledge of and ability to process all Medicare claim types including, but not limited to professional services, ambulance transportation, inpatient facility (DRG) and outpatient facility (APC).
  • Knowledge of standard claims coding such as CPT, ICD-10, DRG and HCPCS.
  • Ability to research and reference Medicare and Medicaid online sites for fee schedule and coverage determination information.
  • Familiarity with Clean Claim Initiative (CCI) edits.
  • Knowledge of and willingness to comply with the provisions of the Health Insurance Portability and Accountability Act (HIPAA).
  • Knowledge of coordination of benefits and NAIC guidelines
  • Knowledge of healthcare benefits structures and insurance procedures, preferably as they exist in an HMO healthcare environment.
  • Knowledge of and experience with an automated claim processing system(s).

7. BS in Criminal Justice with 2 years of Experience

  • Previous customer service, member services, or claims processing experience, or any combination of required education and experience.
  • Advanced Keyboarding Knowledge
  • Intermediate knowledge of Microsoft Office
  • Knowledge of FACETS and/or other computerized claims processing systems as applicable (FEP).
  • Associate degree from a college or technical school
  • Technical knowledge of statutory regulations and medical terminology.
  • Excellent written and verbal communication skills, including the ability to convey technical details to claimants, clients and staff.
  • Ability to interact with persons at all levels in the business environment.
  • Ability to effectively manage claims with moderate supervision.
  • Proficient in Word and Excel

8. BA in Legal Studies with 3 years of Experience

  • Knowledge of coverages provided within various commercial property policies.
  • Catastrophic commercial property claims handling experience.
  • Experience with the Xactimate/Xactware estimating software program.
  • A thorough knowledge of claim processing procedures.
  • Effective negotiating skills.
  • Proven ability to provide exceptional customer service.
  • Strong written/oral communication and interpersonal skills.
  • Ability to effectively and independently manage workload while exhibiting solid judgment.
  • Intermediate PC skills including Word, Excel & PowerPoint.

9. BS in Statistics with 5 years of Experience

  • Fundamental understanding of company claims procedures
  • Strong interpersonal skills (including negotiating and consulting), solid communication skills, both oral & written
  • Professional attitude and customer-service oriented
  • Organized and possess the ability to make quick and sound recommendations.
  • A high-level business understanding of FM Global and a working knowledge of company-based technology are essential. 
  • Minimum college diploma with FM Global experience in loss control and insurance operations or equivalent experience.
  • Experience within another FM Global business segment or equivalent.
  • Ability to obtain information from multiple sources and assimilate data.
  • Strong attention to detail and ability to problem-solve
  • Excellent verbal and written communication skillset

10. BS in Actuarial Science with 7 years of Experience

  • Proficiency in Microsoft Office Suite tools
  • Ability to work over-time, based on seasonal business needs
  • Professional phone skillset
  • Draft correspondence to customers including requests for additional information, coverage letters, and rejection of claim notices
  • Passion for great customer service, including a strong ability to establish a positive rapport with clients, brokers, and business partners
  • Excellent analytical skills, verbal and written communication skills
  • Excellent time management and organizational skills
  • Team-oriented, with the ability to excel in a collegial environment
  • Active insurance adjuster’s license issued by Georgia strongly 
  • Identify and maximize claim settlement opportunities
  • Liaising directly daily with insureds and brokers

11. BS in Business Administration with 4 years of Experience

  • Review and analyze claim documentation
  • Adjust and settle first-party property damage claims
  • Review and analyze policy document
  • Act as the first point of contact on various claim calls and inquiries
  • Assign and work with independent adjusters
  • Review and pay bills from outside vendors
  • Maintaining electronic claim files
  • Issue substantive coverage correspondence to clients and brokers
  • Analytical skills to identify, gather, and organize information
  • Customer-focused attitude and skills to resolve inquiries quickly and effectively
  • Strong verbal & written communication skills
  • Decisive writing skills necessary to complete claim reports
  • Authority Target: 75/50 - depending on LOB

12. BS in Accounting with 3 years of Experience

  • Evaluate policy language and apply it to a claim
  • Utilize face-to-face technology methods in direct response center
  • Interpret and apply customized Insurance policies to real-life situations.
  • Willingness to accept challenges and take on new responsibilities
  • Solid planning & organizational skills including time management and prioritization
  • Certified California Examiner and WCCP
  • In-depth knowledge of appropriate insurance principles and laws for workers’ compensation.
  • Strong written and verbal communication skills.
  • Strong organizational, negotiation skills, strong analytical and interpretive skills.
  • A baccalaureate degree from an accredited college or university
  • Professional certification as applicable to workers’ compensation

13. BS in Economics with 5 years of Experience

  • Ability to work independently and assimilate learning materials on many different subjects from various sources.
  • Excellent interpersonal communication and negotiation skills.
  • Ability to work in a team environment.
  • Technical competence in all aspects of multi-line claims with particular emphasis on customer service.
  • Experience in handling and adjusting claims in all 50 states and possess required licenses.
  • Experience in work-related skills and knowledge.
  • All Examiners must receive certification that meets the minimum standards of training, experience, and skill.
  • WCCA and WCCP are not required but are helpful.
  • A State Worker's Compensation License is required in some branches.
  • Basic understanding of laws and jurisdictional restraints to manage injuries.

14. BS in Risk Management and Insurance with 2 years of Experience

  • Excellent verbal communication skills, time management, and organizational skills.
  • Requires a high level of attention to detail.
  • Sense of urgency for execution.
  • Experience in property adjusting
  • Proficient computer skills and strong organizational skills
  • Detail-oriented and good time management skills
  • Excellent written and verbal communication skills
  • Experience in Xactimate/Symbility
  • Must have experience working as a Staff Adjuster for an Insurance Carrier
  • Must have an active FL adjuster license

15. BS in Health Administration with 6 years of Experience

  • Claims Adjustment experience/ previous claims processing experience.
  • Knowledge in Podiatry, Orthopedic, Dermatology, and/or Pain Management specialties.
  • Knowledge of HIPAA policies and Compliance.
  • Medical Terminology including ICD (10) and CPT Knowledge.
  • Proficient in Microsoft Office programs.
  • Previous experience with systems processing.
  • Research skills and Data Entry and Documentation skills
  • Problem-solving, analytical, and verbal communication skills
  • Ability to interpret medical documentation
Relevant Information
Claims Assessor Skills, Experience, and Job Requirements
Claims Administrator Skills, Experience, and Job Requirements
Claims Associate Skills, Experience, and Job Requirements
Claims Consultant Skills, Experience, and Job Requirements