Claims Adjusters, Examiners, and Investigators
Review settled claims to determine that payments and settlements are made in accordance with company practices and procedures. Confer with legal counsel on claims requiring litigation. May also settle insurance claims.
Sample of reported job titles: Claim Representative, Claims Adjuster, Claims Analyst, Claims Examiner, Claims Representative, Claims Specialist, Corporate Claims Examiner, General Adjuster, Home Office Claim Specialist, Litigation Claim Representative
Tasks | Technology Skills | Tools Used | Knowledge | Skills | Abilities | Work Activities | Detailed Work Activities | Work Context | Job Zone | Credentials | Interests | Work Styles | Work Values | Related Occupations | Wages & Employment | Job Openings | Additional Information
- Examine claims forms and other records to determine insurance coverage.
- Analyze information gathered by investigation and report findings and recommendations.
- Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.
- Investigate and assess damage to property and create or review property damage estimates.
- Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
- Interview or correspond with claimants, witnesses, police, physicians, or other relevant parties to determine claim settlement, denial, or review.
- Investigate, 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.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- Pay and process claims within designated authority level.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- Refer questionable claims to investigator or claims adjuster for investigation or settlement.
- Collect evidence to support contested claims in court.
- Confer with legal counsel on claims requiring litigation.
- Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Present cases and participate in their discussion at claim committee meetings.
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Examine titles to property to determine validity and act as company agent in transactions with property owners.
- Report overpayments, underpayments, and other irregularities.
- Communicate with reinsurance brokers to obtain information necessary for processing claims.
- Prepare reports to be submitted to company’s data processing department.
- Attend mediations or trials.
- Communicate with former associates to verify employment record or to obtain background information regarding persons or businesses applying for credit.
- Negotiate claim settlements or recommend litigation when settlement cannot be negotiated.
Find occupations related to multiple tasks
- Access software — CCC EZNet electronic communications network; CSC Automated Work Distributor AWD
- Analytical or scientific software — Injury Sciences EDR InSight; Insurance claims fraud detection software; Magnify Predictive Targeting System
- Computer aided design CAD software — 4n6xprt Systems StiffCalcs; ARSoftware WinSMAC; PhotoModeler; Visual Statement Investigator Suite (see all 7 examples)
- Data base reporting software — Corporate Systems ClaimsPro
- Data base user interface and query software — Claims processing administration and management software; Fair Isaac Claims Advisor; Tropics Claims Reserve Management
- Desktop publishing software — Microsoft Publisher
- Document management software — Datanex ClaimTrac; Document management system software; Hyland OnBase Enterprise Content Management; InSystems Calligo Document Management System (see all 20 examples)
- Enterprise resource planning ERP software — ADP software; CCC Pathways Appraisal Quality Solution
- Expert system software — Axonwave Fraud and Abuse Management System; Bill review software; LexisNexis RiskWise; StrataCare StrataWare eReview (see all 12 examples)
- Financial analysis software — Automatic Data Processing Estimating; CSC Colossus; Simsol for Adjusters; Turtle Creek Software Goldenseal Architect (see all 6 examples)
- Information retrieval or search software — CGI-AMS BureauLink Enterprise
- Interactive voice response software — Computerized voice stress analyzer CVSA software
- Medical software — Healthcare common procedure coding system HCPCS ; Medical condition coding software ; Medical procedure coding software
- Office suite software — Microsoft Office
- Presentation software — Microsoft PowerPoint
- Spreadsheet software — Microsoft Excel
- Word processing software — Microsoft Word
Hot Technology — a technology requirement frequently included in employer job postings.
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- Customer and Personal Service — Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
- English Language — Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
- Law and Government — Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
- Clerical — Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.
- Mathematics — Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
- Administration and Management — Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
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- Critical Thinking — Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
- Reading Comprehension — Understanding written sentences and paragraphs in work related documents.
- Active Listening — Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
- Speaking — Talking to others to convey information effectively.
- Negotiation — Bringing others together and trying to reconcile differences.
- Writing — Communicating effectively in writing as appropriate for the needs of the audience.
- Active Learning — Understanding the implications of new information for both current and future problem-solving and decision-making.
- Judgment and Decision Making — Considering the relative costs and benefits of potential actions to choose the most appropriate one.
- Complex Problem Solving — Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
- Social Perceptiveness — Being aware of others’ reactions and understanding why they react as they do.
- Monitoring — Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
- Service Orientation — Actively looking for ways to help people.
- Coordination — Adjusting actions in relation to others’ actions.
- Persuasion — Persuading others to change their minds or behavior.
- Time Management — Managing one’s own time and the time of others.
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- Oral Comprehension — The ability to listen to and understand information and ideas presented through spoken words and sentences.
- Written Comprehension — The ability to read and understand information and ideas presented in writing.
- Deductive Reasoning — The ability to apply general rules to specific problems to produce answers that make sense.
- Oral Expression — The ability to communicate information and ideas in speaking so others will understand.
- Inductive Reasoning — The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
- Speech Clarity — The ability to speak clearly so others can understand you.
- Near Vision — The ability to see details at close range (within a few feet of the observer).
- Problem Sensitivity — The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
- Speech Recognition — The ability to identify and understand the speech of another person.
- Written Expression — The ability to communicate information and ideas in writing so others will understand.
- Information Ordering — The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).
- Category Flexibility — The ability to generate or use different sets of rules for combining or grouping things in different ways.
- Mathematical Reasoning — The ability to choose the right mathematical methods or formulas to solve a problem.
- Number Facility — The ability to add, subtract, multiply, or divide quickly and correctly.
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- Interacting With Computers — Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
- Getting Information — Observing, receiving, and otherwise obtaining information from all relevant sources.
- Making Decisions and Solving Problems — Analyzing information and evaluating results to choose the best solution and solve problems.
- Communicating with Supervisors, Peers, or Subordinates — Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
- Resolving Conflicts and Negotiating with Others — Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.
- Identifying Objects, Actions, and Events — Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
- Documenting/Recording Information — Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
- Processing Information — Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
- Evaluating Information to Determine Compliance with Standards — Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
- Communicating with Persons Outside Organization — Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail.
- Organizing, Planning, and Prioritizing Work — Developing specific goals and plans to prioritize, organize, and accomplish your work.
- Analyzing Data or Information — Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.
- Updating and Using Relevant Knowledge — Keeping up-to-date technically and applying new knowledge to your job.
- Establishing and Maintaining Interpersonal Relationships — Developing constructive and cooperative working relationships with others, and maintaining them over time.
- Interpreting the Meaning of Information for Others — Translating or explaining what information means and how it can be used.
- Monitor Processes, Materials, or Surroundings — Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems.
- Judging the Qualities of Things, Services, or People — Assessing the value, importance, or quality of things or people.
- Performing for or Working Directly with the Public — Performing for people or dealing directly with the public. This includes serving customers in restaurants and stores, and receiving clients or guests.
- Performing Administrative Activities — Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
- Thinking Creatively — Developing, designing, or creating new applications, ideas, relationships, systems, or products, including artistic contributions.
- Estimating the Quantifiable Characteristics of Products, Events, or Information — Estimating sizes, distances, and quantities; or determining time, costs, resources, or materials needed to perform a work activity.
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Detailed Work Activities
- Calculate data to inform organizational operations.
- Investigate legal issues.
- Prepare legal or investigatory documentation.
- Estimate costs of goods or services.
- Interview witnesses, suspects, or claimants.
- Appraise property values.
- Negotiate agreements to resolve disputes.
- Supervise employees.
- Advise others on financial matters.
- Implement financial decisions.
- Pay charges, fees, or taxes.
- Verify accuracy of records.
- Maintain data in information systems or databases.
- Report information to managers or other personnel.
- Collect evidence for legal proceedings.
- Meet with individuals involved in legal processes to provide information and clarify issues.
- Examine financial records.
- Prepare financial documents.
- Present business-related information to audiences.
- Confer with others about financial matters.
- Prepare operational reports.
- Gather financial records.
- Advise others on legal or regulatory compliance matters.
- Verify application data to determine program eligibility.
Find occupations related to multiple detailed work activities
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- Electronic Mail — How often do you use electronic mail in this job?
- Telephone — How often do you have telephone conversations in this job?
- Letters and Memos — How often does the job require written letters and memos?
- Frequency of Decision Making — How frequently is the worker required to make decisions that affect other people, the financial resources, and/or the image and reputation of the organization?
- Contact With Others — How much does this job require the worker to be in contact with others (face-to-face, by telephone, or otherwise) in order to perform it?
- Importance of Being Exact or Accurate — How important is being very exact or highly accurate in performing this job?
- Impact of Decisions on Co-workers or Company Results — What results do your decisions usually have on other people or the image or reputation or financial resources of your employer?
- Spend Time Sitting — How much does this job require sitting?
- Deal With External Customers — How important is it to work with external customers or the public in this job?
- Freedom to Make Decisions — How much decision making freedom, without supervision, does the job offer?
- Indoors, Environmentally Controlled — How often does this job require working indoors in environmentally controlled conditions?
- Face-to-Face Discussions — How often do you have to have face-to-face discussions with individuals or teams in this job?
- Importance of Repeating Same Tasks — How important is repeating the same physical activities (e.g., key entry) or mental activities (e.g., checking entries in a ledger) over and over, without stopping, to performing this job?
- Time Pressure — How often does this job require the worker to meet strict deadlines?
- Frequency of Conflict Situations — How often are there conflict situations the employee has to face in this job?
- Structured versus Unstructured Work — To what extent is this job structured for the worker, rather than allowing the worker to determine tasks, priorities, and goals?
- Work With Work Group or Team — How important is it to work with others in a group or team in this job?
- Deal With Unpleasant or Angry People — How frequently does the worker have to deal with unpleasant, angry, or discourteous individuals as part of the job requirements?
- Spend Time Making Repetitive Motions — How much does this job require making repetitive motions?
- Degree of Automation — How automated is the job?
- Level of Competition — To what extent does this job require the worker to compete or to be aware of competitive pressures?
- Coordinate or Lead Others — How important is it to coordinate or lead others in accomplishing work activities in this job?
- Sounds, Noise Levels Are Distracting or Uncomfortable — How often does this job require working exposed to sounds and noise levels that are distracting or uncomfortable?
- Physical Proximity — To what extent does this job require the worker to perform job tasks in close physical proximity to other people?
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|Title||Job Zone Four: Considerable Preparation Needed|
|Education||Most of these occupations require a four-year bachelor’s degree, but some do not.|
|Related Experience||A considerable amount of work-related skill, knowledge, or experience is needed for these occupations. For example, an accountant must complete four years of college and work for several years in accounting to be considered qualified.|
|Job Training||Employees in these occupations usually need several years of work-related experience, on-the-job training, and/or vocational training.|
|Job Zone Examples||Many of these occupations involve coordinating, supervising, managing, or training others. Examples include real estate brokers, sales managers, database administrators, graphic designers, chemists, art directors, and cost estimators.|
|SVP Range||(7.0 to < 8.0)|
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Interest code: CEI Want to discover your interests? Take the O*NET Interest Profiler at My Next Move.
- Conventional — Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow.
- Enterprising — Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business.
- Investigative — Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally.
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- Integrity — Job requires being honest and ethical.
- Dependability — Job requires being reliable, responsible, and dependable, and fulfilling obligations.
- Attention to Detail — Job requires being careful about detail and thorough in completing work tasks.
- Stress Tolerance — Job requires accepting criticism and dealing calmly and effectively with high stress situations.
- Self Control — Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.
- Independence — Job requires developing one’s own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.
- Adaptability/Flexibility — Job requires being open to change (positive or negative) and to considerable variety in the workplace.
- Initiative — Job requires a willingness to take on responsibilities and challenges.
- Persistence — Job requires persistence in the face of obstacles.
- Achievement/Effort — Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks.
- Analytical Thinking — Job requires analyzing information and using logic to address work-related issues and problems.
- Cooperation — Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
- Concern for Others — Job requires being sensitive to others’ needs and feelings and being understanding and helpful on the job.
- Leadership — Job requires a willingness to lead, take charge, and offer opinions and direction.
- Innovation — Job requires creativity and alternative thinking to develop new ideas for and answers to work-related problems.
- Social Orientation — Job requires preferring to work with others rather than alone, and being personally connected with others on the job.
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- Support — Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical.
- Independence — Occupations that satisfy this work value allow employees to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy.
- Working Conditions — Occupations that satisfy this work value offer job security and good working conditions. Corresponding needs are Activity, Compensation, Independence, Security, Variety and Working Conditions.
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