Identifies exposures and refers files or features for triage to the appropriate level including referring injury claims to the appropriate level
Dispatches total loss assignments • Reviews ISO, Accurint, and other claims databases to verify information related to handling of total loss
You will need to work with body shops or contractors in order to come to an agreed repair price. We strongly prefer experienced material damage
Assigns, directs and monitors rehabilitation and medical case management activities in accordance with the Claim Guidelines and industry Best Claim
As a Claims Examiner, you will be primarily responsible for the direct handling of serious property Damage (PD) and Bodily Injury (BI) claims and
We do the same for our employees. We are process and domain experts, focused on the solutions that deliver results for our clients and our company
Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim and, if so, how much.
Claims adjusters, appraisers, examiners, and investigators typically do the following:
Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. For example, workers in property and casualty insurance must know housing and construction costs to properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable.
Adjusters inspect property damage to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.
Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.
Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.
If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer’s position.
Some claims adjusters work as self-employed public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company’s adjuster. The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.
Sometimes, self-employed adjusters are hired by insurance companies in place of hiring adjusters as regular employees. In this case, the self-employed adjusters work in the interest of the insurance company.
Appraisers estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.
Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.
Most claims examiners work for life or health insurance companies. Examiners who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator.
Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies, to make sure that the applicants have no serious illnesses that would make them a high risk to insure.
Insurance investigators handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of damage to vehicles to complicated fraud rings. Investigators often do surveillance work. For example, in the case of a fraudulent workers’ compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be ruled out by injuries stated in the claim.
Claims adjusters, appraisers, examiners, and investigators held about 315,300 jobs in 2014. The industries that employed the most claims adjusters, appraisers, examiners, and investigators were as follows:
|Agencies, brokerages, and other insurance related activities||24|
|State and local government, excluding education and hospitals||4|
|Management of companies and enterprises||3|
Claims adjusters and examiners spend time in offices, reviewing documents and conducting research; they work outside when examining damaged property. Appraisers and investigators work outside more often, inspecting damaged buildings and automobiles and conducting surveillance. Auto damage appraisers spend much of their time at automotive body shops, estimating vehicle damage costs.
Workers who inspect damaged buildings must be wary of potential hazards, such as collapsed roofs and floors, as well as weakened structures.
Most claims adjusters, appraisers, examiners, and investigators work full time. However, their work schedules vary.
Adjusters often arrange their work schedules to accommodate evening and weekend appointments with clients. This requirement sometimes results in adjusters working irregular schedules, especially when they have a lot of claims to review.
In contrast, auto damage appraisers typically work regular hours and rarely work on weekends, although they frequently spend much of their time at automotive body shops, estimating vehicle damage costs.
Insurance investigators often work irregular schedules because of the need to conduct surveillance and contact people who are not available during normal business hours. Early morning, evening, and weekend work is common.
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A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. Higher level positions may require a bachelor’s degree or some insurance-related work experience. Auto damage appraisers typically have either a postsecondary nondegree award or work experience in identifying and estimating the cost of automotive repair.
A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. However, employers sometimes prefer to hire applicants who have a bachelor’s degree or some insurance-related work experience or vocational training. Auto damage appraisers typically have either a postsecondary nondegree award or experience working in an auto repair shop, identifying and estimating the cost of automotive repair.
The varying types of work in these occupations can require different backgrounds or different college coursework. For example, a business or an accounting background might be best for someone who wishes to specialize in claims of financial loss due to strikes, equipment breakdowns, or merchandise damage. College training in architecture or engineering is helpful for adjusting industrial claims, such as those involving damage from fires or other accidents. A legal background is beneficial to someone handling workers’ compensation and product liability cases. A medical background is useful for examiners working on medical and life insurance claims.
Although auto damage appraisers are not required to have a college education, most companies prefer to hire people who have the formal training, experience, or knowledge and technical skills to identify and estimate the cost of automotive repair. Many vocational schools and some community colleges offer programs in auto body repair and teach students how to estimate the cost of repairing damaged vehicles.
For investigator jobs, a high school diploma or equivalent is the typical education requirement. Most insurance companies prefer to hire people trained as law enforcement officers, private investigators, claims adjusters, or examiners, because these workers have good interviewing and interrogation skills.
At the beginning of their careers, claims adjusters, examiners, and investigators work on small claims, under the supervision of an experienced worker. As they learn more about claims investigation and settlement, they are assigned larger, more complex claims.
Auto damage appraisers typically get on-the-job training, which may last several months. This training usually involves working under the supervision of a more experienced appraiser while estimating damage costs, until the employer decides that the trainee is ready to do estimates on his or her own.
Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state. Some states have few requirements; others require either completing prelicensing education or receiving a satisfactory score on a licensing exam (or both).
In some states, claims adjusters employed by insurance companies do not have to become licensed themselves because they can work under the company license.
Public adjusters may need to meet separate or additional requirements.
Some states that require licensing also require a certain number of continuing education credits per year to renew the license. Federal and state laws and court decisions affect how claims must be handled and what insurance policies can and must cover. Examiners working on life and health claims must stay up to date on new medical procedures and the latest prescription drugs. Examiners working on auto claims must be familiar with new car models and the most recent repair techniques. In order to fulfill their continuing education requirements, workers can attend classes or workshops, write articles for claims publications, or give lectures and presentations.
Analytical skills. Adjusters and examiners must both evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay. Adjusters must carefully consider various pieces of information to reach a decision.
Communication skills. Claims adjusters and investigators must get information from a wide range of people, including claimants, witnesses, and medical experts. They must know the right questions to ask in order to gather the information they need.
Detail oriented. Adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences.
Interpersonal skills. Adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering. These workers must be understanding, yet firm with their company’s policies.
Math skills. Appraisers must be able to calculate property damage.
The median annual wage for claims adjusters, examiners, and investigators was $62,220 in May 2014. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $37,580, and the highest 10 percent earned more than $92,620.
The median annual wage for insurance appraisers, auto damage was $63,420 in May 2014. The lowest 10 percent earned less than $43,510, and the highest 10 percent earned more than $90,840.
In May 2014, the median annual wages for claims adjusters, appraisers, examiners, and investigators in the top industries in which they worked were as follows:
|Management of companies and enterprises||61,500|
|Agencies, brokerages, and other insurance related activities||58,940|
|State and local government, excluding education and hospitals||58,310|
Most claims adjusters, appraisers, examiners, and investigators work full time. However, their work schedules vary.
Employment of claims adjusters, appraisers, examiners, and investigators is projected to grow 3 percent from 2014 to 2024, slower than the average for all occupations.
Employment of claims adjusters, examiners, and investigators is projected to grow 3 percent from 2014 to 2024, slower than the average for all occupations. Employment growth should stem primarily from the growth of the health insurance industry. Federal legislation mandating individual coverage may increase the number of health insurance customers, including high-risk individuals who are more likely to file claims. Any such increase is expected, in turn, to increase the demand for claims adjusters to determine which treatments are approved and how much the company will pay.
In addition, rising medical costs may result in a greater need for claims examiners to carefully review a growing number of medical claims. An increase in the number of claims being made by a growing elderly population also should spur demand for health insurance claims adjusters and examiners.
The number of natural disasters, such as floods and fires, influences demand for claims adjusters in property and casualty insurance. Future increases in the number of natural disasters could result in strong employment growth for claims adjusters in the field.
All of the preceding factors will be somewhat offset by automation. Technology allows less complex claims to be processed automatically, freeing adjusters to work on more complex claims. As a result, fewer adjusters are needed per claim, reducing the number of adjusters required on staff.
Employment of auto damage appraisers is projected to decline 1 percent from 2014 to 2024. In recent years, the number of automobile accidents relative to the population has declined. As automobiles become safer, the number of traffic accidents is expected to decline as well, leading to decreased demand for the services of auto damage appraisers.
Job opportunities for claims adjusters and examiners should be best in the health insurance industry as the number of health insurance customers expands. In addition, prospects for claims adjusters in property and casualty insurance will likely be best in areas susceptible to natural disasters. These areas include the Gulf Coast, which can have a large number of hurricanes, and the West Coast, which is vulnerable to wildfires.
|Occupational Title||Employment, 2014||Projected Employment, 2024||Change, 2014-24|
|Claims adjusters, appraisers, examiners, and investigators||315,300||324,900||3||9,600|
|Claims adjusters, examiners, and investigators||299,700||309,500||3||9,800|
|Insurance appraisers, auto damage||15,500||15,400||-1||-200|