Claims Adjusters, Examiners, and Investigators

Jobs as Claims Adjusters, Examiners, and Investigators involve not only medical billing tasks, but require a number of other skills as well. Because non-medical facets of the job are part of the whole package, information has been included below on the entire scope of these jobs for the sake of completeness and accuracy.

Nature of the Work

Most Insurance Claims jobs are found in insurance companies, where claims are submitted after an accident, injury, or loss of some kind. These claims are reviewed and acted upon by claims adjusters, appraisers, examiners and investigators. Their primary role is to investigate those claims, negotiate settlements, and authorize payments to policy holders after determining whether or not the customer's insurance policy covers the loss. This is generally not a single job, but usually several jobs done by a group of people working together to resolve the claim.

Adjusters gather the information needed to assess and process an insurance claim. They investigate the nature and scope of the claim by interviewing the policyholder and any witnesses, reviewing police or hospital records, and assessing property damage. They may work with experts in their fields (such as doctors, construction workers, or lawyers) if needed to make a more educated evaluation of the damages. Adjusters then prepare a written report that is used to determine what will or will not be covered by the insurance company. If a claim is contested, the adjusters work in conjunction with lawyers on behalf of the insurance company.

Examiners who work for insurance companies often perform many of the tasks an adjuster does, but their job often focuses on reviewing the claims which have been submitted to be sure the relevant guidelines have been adhered to. For example, guides which give the typical treatments, average hospital stay, and average recovery/treatment time for specific injuries are used to see if costs submitted by the policyholder are reasonable. They will then either authorize payment to the insured, or refer the claim for further review, usually to a senior examiner who may specialize in a particular field.

Investigators are used when insurance fraud is suspected. These investigators look into claims where arson, unnecessary medical treatment, criminal activity, or worker's disability abuse is suspected. Background information about claimants is gathered to assess any prior attempts at insurance fraud or other criminal activity have ever taken place. Investigators then interview the claimant and any witnesses to create a written record, take pictures or video that may be used as evidence, and may also do surveillance to assess the plausibility of the claim.

Training and Qualifications Needed

Although a college degree is not required, most companies give preference to college graduates; approximately three quarters of those employed in this field have at least some college, and about 50% hold a bachelor's degree or higher. Degree programs are not generally offered specifically for claims adjusters, examiners, and investigators, but several degrees could be beneficial for people applying for these jobs. For example, training, education or experience in a medical setting would be useful in assessing medical and life insurance claims.

Training or experience in a related field is desirable. People trained in law enforcement make excellent insurance investigators since they have experience in interviewing people to assess the situation in an accident or event. Successful auto collision appraisers often have experience in repairing vehicles so that they are familiar with what work will need to be performed. In this case, vocational training in auto body repair is recommended.

Many entry level jobs will give on-the-job training under the supervision of a more experienced worker.

Continuing education is expected of people in these jobs so that they keep current on new Federal and State laws which affect how claims are processed, as well as with new medical treatments and drug therapies which may be used.

Licensing requirements vary by state; some states require a licensing exam, whereas others require a specific number of continuing education credits.

Opportunity for Advancement

With experience, people in these jobs may be promoted to management or administration. Some people may opt to start their own business as an independent claims adjuster or appraiser.

Long Term Job Outlook

Job growth over the next several years is expected to be about as fast as the average for all jobs. As population increases, the number of insurance policies will grow, creating new jobs. Competition will be brisk for claims adjusters, examiners, and investigators, but people with related training or experience will have the best opportunity for successfully obtaining one of these jobs.

Salary and Earnings Potential

The salary for claims adjusters, examiners and investigators varies widely. According to the Bureau of Labor Statistics, the middle fifty percent of workers in these jobs earned between $38,520 and $65,210. Training, experience, and area of the country will influence salary.


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