What does a Claims Representative do?

Customer service, claims processing, and problem resolution are all responsibilities of a claims representative. These representatives work in a variety of industries, but the service sector is the most common. Government benefit agencies and insurance companies are both potential employers.

Customers who need to file a claim should contact the claims representative first. A claim is used to request reimbursement for a payment or to gain access to benefits provided an insurance program. Regular payments are made clients in order to obtain insurance or benefit coverage. He or she contacts the insurance company to file a claim against the policy when a related expense occurs.

Answering incoming phone calls, emails, and letters is part of customer service. The claims representative examines the information provided, consults the client’s company policy, and determines whether the expense claimed is covered. If any missing information or additional information is required, the representative contacts the client to resolve these issues.

Claims representatives are in charge of entering data into the computer system or reviewing claims and making a preliminary assessment. The review is frequently used to identify processing errors or missing data. The representative can approve, deny, or escalate a claim after a thorough review. Typically, the escalation process sends the claim to a supervisor, who can review it in greater detail and make a decision.

Delays in payment processing, customer account renewal issues, modifying account information, and fielding complaints are all problems that a claims representative is responsible for solving. In many cases, the representative collaborates closely with various departments to help the client resolve the issue. When a situation cannot be resolved within a certain amount of time, it is escalated to a supervisor.

A standard office cubical, complete with a computer and telephone, is the work environment for someone in this position. He or she spends the majority of his or her time at a desk, working on a computer. In this position, there is very little direct physical contact with clients.

A combination of education and related experience is required to become a claims representative. The level of training required varies industry. An insurance company, for example, may provide extensive training to all claims representatives while also requiring successful completion of a post-secondary business or customer service program. Most government agencies prefer candidates who have completed at least a year of training, but they also offer a comprehensive training program.