A claims adjudicator investigates various insurance claims in order to determine if a claim is eligible for a cash settlement or if it should be denied or negotiated. In order to reach a decision, claims adjudicators perform research into insurance claims and often conduct interviews with police officers, policy holders, doctors and other professionals or individuals who may be involved.
Claims adjudicators, commonly known as claims adjusters, work in the insurance industry processing claims for insurance companies. They investigate and negotiate claims filed by insurance policy holders. Claims adjudicators must have knowledge of the insurance industry and excellent communication skills.
|Required Education||Variable depending on state and industry|
|Common Employment Industries||Insurance, healthcare, public sector|
|Projected Job Growth (2014-2024)||-11% * (for insurance underwriters)|
|Median Salary (2015)||$62,980 annually * (for claims adjusters, examiners, and investigators)|
Source: *U.S. Bureau of Labor Statistics
Claims Adjudicator Job Description
Claims adjudicators, also referred to as claims adjusters, process insurance policy holders' claims of injury, damage or loss. The job of a claim adjudicator involves interviewing claimants, witnesses, law enforcement officers and physicians as well as reviewing medical or police records. After investigating a claim, the adjuster will deny, pay or negotiate a settlement with the policy holder or his or her representatives.
Generally, claim adjudicators who work in the health care industry or for health insurance companies are known as medical bill advocates. Their job is to determine the amount of money that will be paid on a medical claim after the policy holder's insurance benefits and deductibles have been considered.
Usually, claims adjudicators are employed by insurance companies that provide property, casualty and liability insurance. However, they can work for independent adjudication firms, third-party claims administration companies or as public adjudicators, adjusters that are hired by insured clients who have experienced damage or loss.
Claims Adjudicator Job Requirements
Education and training requirements to become a claims adjudicator are variable because licensing requirements vary by state. Certain states require no education or licensing, while others require specific licensing education, a licensing exam with a passing score and a specified amount of continuing education hours.
The U.S. Bureau of Labor and Statistics (BLS), indicates that while there are no specific college majors recommended for the position, having a college degree in the area that the claims adjudicator specializes in is beneficial (www.bls.gov). For instance, a licensed psychologist working for a health insurance company processing medical claims would possess intricate knowledge and details about the workings of the industry. That knowledge would be an asset for the claims adjudicator and the health insurance company.
Though training and education is variable, most employers provide additional educational opportunities for their claims adjudicators. When entry-level claims adjudicators are hired, they are supervised by senior workers and are given less complicated cases until achieving competency.
Many companies also conduct seminars and offer supplemental training to expand adjudicators' knowledge of their positions and to help them keep abreast of changes in industry policy impacted by state or federal regulations. Still, most employers give preference to claims adjudicator applicants who are college graduates and individuals with relevant insurance industry experience.
Employment Options, Outlook and Salary Information
The BLS reports that jobs for insurance underwriters are expected to decline by 11% between 2014 and 2024. This decline is due in large part to automated software that allows underwriters to process a claim far more quickly than in the past. In 2015, the BLS noted an annual median salary of $62,980 for claims adjusters, examiners and investigators.
A college degree and insurance industry experience is recommended to become a claims adjudicator. In some states, claims adjudicators need to have a license, while in other states there are not any sort of licensure or education requirements for the profession. Common employers of these professionals include insurance companies, adjudication firms, or organizations dedicated to handling third-party claims.