An insurance claims manager is someone who processes payment claims, answers questions about them, and reports any issues to a supervisor or investigator. Depending on the insurance product and the insurance company, the process for approving claims may differ slightly. A life insurance policy, for example, may only require a death certificate to process a claim. Health insurance claims can be much more complicated, involving consultations and pre-approvals for treatment.
Following the receipt of a claim, an insurance claims manager, also known as an insurance claims adjuster, examines the policy in question. The manager will then compare the nature of the claim to the types of claims covered the policy. If there is a match, either fully or partially, a full or partial benefit may be paid. If a medical procedure is covered but the insured person sees an out-of-network doctor, for example, only a portion of the claim may be paid. The remainder is the patient’s responsibility.
There are many reasons why a claim may be delayed or denied outright. This can happen if an insurance claims manager believes the proper procedures for filing a claim, as outlined in the insurance agreement, were not followed. In such cases, the insurance policyholder may be able to use an appeals procedure. The insurance claims manager may be required to submit a report outlining why the claim was denied or delayed.
When there is a delay, it is usually because the insurance claims manager has reason to believe there is a possibility of fraud. This is most common in the case of automobile and life insurance. Because some claims may be difficult to verify, these have a higher risk of fraud. The reason for the delay is usually that the insurance company wants to conduct its own investigation into the claim’s validity. If no substantial evidence of fraud is discovered at the conclusion of the investigation, the claim will most likely be approved.
In order to work as an insurance claims manager, you must have a Bachelor’s degree at the very least. The majority of people who are interested in insurance study business, business administration, or finance. These are subjects that are generally related to the insurance industry, but they also provide a good foundation for work in other fields. An insurance agent, with or without a college degree, may be able to advance to the position of claims manager.