Claims Examiner
Medical Office Administration
Perform specialized investigatory, analytical, evaluative, and consultative functions related to health/medical insurance operations and their regulation.
What Claims Examiners Do
Perform specialized investigatory, analytical, evaluative, and consultative functions related to health/medical insurance operations and their regulation.
Common Tasks
- 1Examine claims forms and other records to determine insurance coverage.
- 2Analyze information gathered by investigation and report findings and recommendations.
- 3Pay and process claims within designated authority level.
- 4Investigate, evaluate, and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
- 5Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
What You'll Learn
Types of Claims Examiners
Work Environment
Locations
- • Health insurance company offices
- • Third-party administrator (TPA) offices
- • Remote/work-from-home settings
- • Corporate claims departments
- • Field investigation sites (as needed)
Schedule
Most work a standard weekday schedule with set hours, though deadlines and high claim volume can create time pressure and occasional overtime.
Physical Demands
Work is primarily desk-based with long periods of sitting and computer use. Physical activity is generally low, with occasional handling of documents and limited field visits depending on the role.
Salary & Job Outlook
National Employment: 356,100 jobs
Top Paying States
Why Demand May Grow
Demand can rise as healthcare costs and insurance complexity increase, creating more claims that need careful review for coverage and compliance. Growth in fraud detection and regulatory oversight can also increase the need for skilled examiners and investigators.
Skills You'll Need
Pros & Cons
Pros
- • Stable office-based work with clear procedures
- • Strong median pay compared with many administrative roles
- • Transferable skills across insurance and healthcare administration
- • Opportunities to specialize (medical, disability, fraud, litigation support)
- • Often eligible for remote or hybrid work
Cons
- • High time pressure and productivity metrics
- • Work can be repetitive and detail-heavy
- • Emotional strain when dealing with disputes or denied claims
- • Employment may decline due to automation and process streamlining
- • Requires staying current on regulations and policy changes
Common Questions About the Claims Examiner Trade
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