What is a claims examiner?
Examiners also check claim submittals for completeness and accuracy and communicate with on-staff medical specialists in order to verify the information reported in the claim. Examiners will then either authorize the appropriate payment or refer the claim to an investigator for a more thorough review. Claims examiners usually specialize in group or individual insurance plans, since the way that claims are treated will vary depending on the type of coverage held by the plan member. Claims review decisions will also vary based on the plan description, since not all plans offer the same benefits. So, the claims examiner should not only be familiar with medical procedures and prescription drugs, they must also fully understand all of the different plans offered through the insurance company for whom they work. Some states require that claims examiners pass a state issue exam and become licensed in this profession. 1 CommentLeave a comment |
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What is a claims examiner?
This is usually an employee of the insurance company who has the responsibility of reviewing claims from members to verify that they are a covered benefit under the member’s policy and are not excluded by the plan’s limitations or exclusions. They are in charge of the claims eligibility review process and determine if a claim is to be sent to accounts payable for processing or if the plan member is to be informed of the claim denial. The examiner must also review health-related claims to see if the costs submitted by the heath care provider are reasonable for the medical services that were rendered. If the claim is submitted by the insured, or through a non-participating provider, the examiner must determine if the fees submitted are considered “usual, customary and reasonable.” An examiner is provided with guides that provide them with these reasonable rates, which can vary geographically and by the type of service provided. The claims examiner must also be familiar with expected treatments for a specific illness and the average hospital stay or follow-up treatments and procedures required to properly treat and cure that illness.
Hey guys, maybe this isn’t the right place to ask or maybe it is! I am considering making a career change soon and somehow I ended up with being offered a junior position leading to becoming a claims examiner with Blue Cross of Illinois. It’s not set in stone by any means, I only heard about it from my cousin to seems to be doing well and he said he could probably get me in the door if he wanted to. But I have no idea what the insurance business is like these days. Is there money to be made? I thought the business wasn’t doing too well with all the lawsuits and stuff?
Anyway, do you know what education I need to become a claims examiner if any? I am a college graduate.
Comment by Curtis — June 22, 2009 @ 12:18 pm