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What Does a Claims Representative Do?

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  • Written By: Carol Francois
  • Edited By: A. Joseph
  • Last Modified Date: 04 July 2014
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A claims representative is responsible for providing customer service, processing claims requests and resolving problems. These representatives can be found in multiple industries but are most commonly found in the service sector. Potential employers include government benefit agencies and insurance companies.

The claims representative is the first point of contact for customers who need to file a claim. The purpose of a claim is to request reimbursement of a payment or to access benefits paid for through an insurance program. Clients make regular payments to obtain insurance or benefit coverage. When a related expense occurs, he or she contacts the insurance company to make a claim against that policy.

Customer service includes answering incoming phone calls, emails and letters. The claims representative reviews the information provided, accesses the client's policy with the company and determines if the expense claimed is covered. If there is any missing information or if further details are required, the representative initiates contact with the client to resolve these issues.

Claims representatives are responsible for entering the data into the computer system or reviewing the claim and making an initial assessment. In many cases, the review is designed to spot processing errors or missing information. After careful review, the representative can approve, deny or escalate a claim. The escalation process typically sends the claim to a supervisor who can review the claim in more detail and make a decision.

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The types of problems that a claims representative is responsible for solving include delays in payment processing, customer account renewal issues, modifying account information and fielding complaints. In many cases, the representative works closely with the various departments to resolve the problem on behalf of the client. Situations that cannot be resolved in a specific time frame are escalated to a supervisor.

The work environment for a person in this position is a standard office cubical, complete with a computer and telephone. He or she sits at a desk and works on the computer the vast majority of the time. There is very little direct physical contact with clients in this role.

In order to become a claims representative, a combination of education and related experience is required. The actual level of training varies by industry. For example, an insurance company will provide detailed training to all claims representatives but might also require successful completion of a post-secondary program in business or customer service. Most government agencies prefer candidates with at least one year of training, but they also provide a detailed training program.

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Discuss this Article

OceanSwimmer
Post 5

@cellmania- I can see where you would be very frustrated with how that turned out. I worked as a claims secretary for many years. During that time, I can't count the number of times I was cursed at, yelled at, and hung up on. After a while, I changed the way I did things.

I started talking to people on their level. I spoke to them as if I were experiencing the same loss that they had experienced. I empathized with them and provided individualized and informative advice and suggestions. Of course, there are always the ones that are very angry when there is something that their policy doesn't cover. In those cases, I apologize that their insurance policy doesn't cover the particular claim. I then explain to them what changes they could make to their policy for the best price and provide the future coverage that they might need.

It works much better when you have a good attitude and can be empathetic.

CellMania
Post 4

I know that they are just doing their job but sometimes they get on my nerves so bad! I have had my car insurance with the same company for years. I have never filed a claim. Two of the vehicles on our policy only have liability insurance. I accidentally backed into one of the cars while driving the other one.

I called the claims representative to ask a simple question. I wanted to know if the liability on one vehicle would pay for the damage to the other vehicle. She would not answer me. She said we had to do a claims report on it. We had to go through the whole process and I had to tell her that I was driving and that I had my seat belt on. Then, she wanted to know how far apart the vehicles were.

After going through all of this, she told me that my liability would not cover another vehicle on my policy. She could have told me that at the beginning! About a week later, I get a letter from my insurance company telling me that my premium went up substantially because they counted that incident as an “accident” that was my fault. I was so frustrated with the claims representative for what she did. I transferred all of my insurance the next day to another company.

bagley79
Post 3

When my kids were learning to drive I had three of them at one time that were at home and had cars of their own. Unfortunately, I knew my auto insurance claims representatives phone number by heart.

She was always very helpful and understanding, but that is one phone number that you really don't want to have memorized. Between adding different vehicles and some wrecked cars, I spent more time than I wanted talking to this claims representative.

John57
Post 2

My first job out of college was working for a hospital as a claims representative. This position was not as easy as it sounded like it would be at first.

There were many medical situations I came across that were quite unique and required some extra work. In addition to that, the guidelines and policies were frequently changing.

I was in an entry level position at the time, and had to rely on my supervisor who had many years of experience to help me make the best decisions on those claims.

This job did help me become more aware of how the process works and the challenges and frustrations that are on both ends of the claim process.

Mykol
Post 1

Working as a claims representative in the insurance industry can be quite challenging sometimes.

Many times the people making the claims have had something traumatic happen, so you can understand they are overwhelmed and anxious to get the claim resolved as quickly as possible.

I worked several years as a claims representative and found that the job required a balance of paperwork and good customer service skills.

I always tried to give good customer service while resolving the claim on a timely basis. I was always thankful for those people who were patient and worked with me instead of being very demanding, as many of them could be.

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