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What Does a Claims Analyst Do?

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  • Written By: Mary McMahon
  • Edited By: O. Wallace
  • Last Modified Date: 04 August 2014
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A claims analyst evaluates claims submitted to insurance companies to determine whether or not the claims meet the eligibility standards of the company. People in this position may also work for customer complaint and fraud departments at companies like banks and big retailers, handling customer complaints. In all cases, claims analysts need to have an excellent eye for detail, and an extensive knowledge of the industry they work in, to ensure that they offer an appropriate level of care to customers.

One of the most classic fields of employment for a claims analyst is in the health insurance industry. They can also handle car insurance, life insurance, home insurance, warranty claims, and other situations in which a customer or consumer submits a claim to a company for payment or another action. Training for this job usually involves obtaining a certificate or degree in the field in which a claims analyst intends to work, supported by credentialing in office procedure and the specific procedures involved with both billing and claims processing.

When a claim is submitted to a company, the claims analyst first scans it to determine whether or not the claim is complete and accurate. He or she may request additional information such as documentation, test results, and other material which could be relevant to the claim. After collecting all of the necessary information, the analyst can determine whether or not the claim is eligible for payment, and send out a payment or denial letter, depending on the circumstances.

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A claims analyst usually works under the supervision of someone else, such as a senior claims analyst who heads a department, a billing specialist, or a more generalized administrator. These professionals are usually trained to adhere to company policy as much as possible when handling claims, and to err on the side of denial rather than default acceptance of claims. This is designed to trim expenses for the company, and to reduce the risk of paying out on fraudulent, incomplete, or marginally eligible claims.

When people receive a denial letter, they can opt to appeal the decision, asking for additional review along with the reasons that the claim was denied. This review may be conducted by another claims analyst, or by someone who is retained specifically to handle appeals. When appealing claims, it helps to get as much information about company policy and how the claim was processed as possible, to look for potential areas of contention or weak spots which could be used to dispute the denial.

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Discuss this Article

anon268026
Post 3

@Alfredo: You just want people to pay out money to you without identifying your risk factors and the possibility that you may be lying? The reason you are getting a ballpark figure is because we have certain variables and procedures that we need to follow to ensure that we are protecting our assets and not being taken advantage of.

tolleranza
Post 2

@alfredo - I have a friend who is actually a risk management analyst (which falls under the larger umbrella of a claims analyst) and that type of job makes on average 62,000 per year.

She also had to get an undergraduate degree and a few special professional credentials, which she received after taking some intense tests (I helped her study for one - talk about meticulous stuff). So she might make even more than your typical claims analyst.

aLFredo
Post 1

I do not know if these employees are different from a claims analyst but I always dislike talking anyone from my insurance company regarding possible claims.

I try to call ahead when I have a new procedure being completed, like when I had a crown put in to replace a tooth, so I won’t be hit with any surprise fees or “Oops we don’t cover that” from the insurance company.

When I called to find out about how much it would be it seemed to take forever to get any sort of answer. There would misunderstandings and many if and buts that I could do nothing better than get a ballpark figure.

I wonder how much someone who has a claims analyst job makes a year? If they are the same person that I am talking to on the phone, I hope their company makes enough to pay for more job training!

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