A claims analyst examines claims submitted to insurance companies to determine whether they meet the company’s eligibility requirements. Customer complaint and fraud departments at banks and large retailers may employ people in this position to handle customer complaints. To provide an appropriate level of care to customers, claims analysts must have an excellent eye for detail and a thorough understanding of the industry in which they work.
The health insurance industry is one of the most traditional places for a claims analyst to work. They can also handle claims for car insurance, life insurance, home insurance, warranty claims, and other situations in which a customer or consumer submits a claim to a business for payment or another action. Obtaining a certificate or degree in the field in which a claims analyst intends to work, as well as credentialing in office procedure and the specific procedures involved with both billing and claims processing, is usually required for this job.
When a company receives a claim, the claims analyst first scans it to see if it is complete and accurate. He or she may ask for more information, such as documentation, test results, and other materials related to the claim. After gathering all of the necessary information, the analyst can determine whether the claim is eligible for payment and, depending on the circumstances, send a payment or denial letter.
A claims analyst is usually supervised someone else, such as a department’s senior claims analyst, a billing specialist, or a more generalized administrator. When handling claims, these professionals are typically trained to follow company policy as closely as possible, and to err on the side of denial rather than default acceptance. This is done to save money for the company and reduce the risk of paying out on claims that are fraudulent, incomplete, or only marginally eligible.
People who receive a denial letter have the option to appeal the decision, requesting additional review as well as the reasons for the claim’s denial. This review could be done a different claims analyst or someone hired specifically to deal with appeals. When appealing claims, it’s a good idea to gather as much information as possible about the company’s policies and how the claim was handled in order to look for potential points of contention or flaws that could be used to refute the denial.