What does a Claims Examiner do?

A claims examiner is someone who works with people who are looking for monetary compensation from insurance companies. The job of a claims examiner is to either deny or approve a claim. To determine whether a claim should be rewarded, an examiner must be aware of the red flags associated with fraudulent claims and possess detailed analysis skills.

Claims examiners are used to detect fraud in the areas of bankruptcy, healthcare, taxation, insurance, consumer fraud, and even money laundering. Examiners are needed many companies to detect fraudulent activity because it saves money for both the company and the customer.

Investigating a claim is similar to deciphering a puzzle. The claims examiner’s job is to determine whether or not a claim is legitimately filed, as well as whether or not the person who filed the claim is providing accurate information. The examiner is able to distinguish between those who truly require assistance and those who are attempting to take advantage of the system. A claims examiner’s main responsibilities include reviewing documentation and conducting private investigations. To gain a visual perspective of the situation, a claims examiner may need to place an individual or corporation under surveillance.

Many businesses, particularly in the insurance and workers’ compensation industries, are in desperate need of qualified claim examiners. Many examiners are in charge of keeping costs down because they are well-versed in the company’s policies and can determine whether or not a claim should be paid. In some cases, a claims examiner must obtain certification to ensure that they can review claims responsibly and recognize when fraud is occurring.

When working for a company, the examiner needs to be well-versed in their field. A claims examiner for a medical insurance company, for example, must be familiar with a variety of medical conditions and illnesses. They must also know which medical records are crucial to the investigation and how a physical condition or ailment can be legitimized in various ways.

A claims examiner is sometimes in charge of detecting asset misappropriation in businesses. Claims examiners are used the legal system to look into cases of fraud involving small businesses and even large corporations. A judge appointed a claims examiner in 2002 to look into claims of fraud at Enron Corporation, a multibillion-dollar company involved in money laundering. Many claims examiners play an important role in developing fraud prevention policies as well as ethics programs and guidelines that help to prevent or reduce fraud.