Insurance claims processors evaluate whether to issue a payment (and how much) on an insurance claim by a policy-holder. Those in this position may work alongside investigators or other claims agents to establish the validity and accuracy of claims; then, they will determine whether the policy offers coverage and issue the appropriate payment.
Many insurance claims simply require accuracy assessments; for medical insurance claims, for example, the processor simply ensures that all necessary forms are included and that the documentation is complete. He/she then issues payment in accordance with the individual policy involved in the claim.
For more complicated claims, these processors may need to work with the issuing agent and seek the help of a claims investigator to ensure the accuracy of reported information. The processor then determines the validity of the claim and extent of payment based on the information gathered.
Claims processors may also adjust insurance policies themselves. Many bulk insurance providers, such as companies covering employees for health care, will specify the benefits they would like to retain for employees. The processor helps adjust the policy plans and then refers any suggested premium changes to the representative of the insurance company which handles the account.
Applicants for the position should have at least some post-secondary school training from a community college or vocational school, either of which may offer training and certification in this career path. Many may work as junior claims adjustors or in a similar but smaller role within an insurance company hierarchy to gain practical experience before applying for this position. Most claims processors work in office environments during traditional business hours.
Insurance Claims Processor Tasks
Update database and process necessary paperwork.
Reviews claims for accuracy and completeness, verify eligibility and coverage level.
Assists in making claim settlement determinations.
Provides customer service to clients.