What is an Insurance Claims Manager?

Ken Black

An insurance claims manager is an individual who processes claims for payment, answers any questions about those claims, and forwards concerns on to a supervisor or investigator. The process of approving claims may be slightly different, depending on the insurance product and insurance company. For example, a life insurance product may require simply a death certificate to process a claim. Health insurance claims can be much more complicated, involving consultation and treatment pre-approvals.

Health insurance claims sometimes involve consultations.
Health insurance claims sometimes involve consultations.

After a claim comes in, an insurance claims manager, also known as an insurance claims adjuster, will look at the specific policy in question. The manager will then compare the nature of the claim to those, which the policy covers. If there is a match, or a partial match, a full benefit or partial benefit may be paid. For example, if a medical procedure is covered, but the insured person uses an out-of-network physician, it may be that only a portion of the claim will be paid. The patient is responsible for the rest.

Health insurance claims usually involved some sort of negotiation between the insurer and the healthcare provider.
Health insurance claims usually involved some sort of negotiation between the insurer and the healthcare provider.

There could be many times when a claim is delayed or denied outright. This may happen when an insurance claims manager believes proper procedures for making the claim were not followed, as outlined in the insurance agreement. In such cases, there may be an appeals procedure available to the insurance policyholder. The insurance claims manager may have to file a report detailing exactly why the claim was delayed or denied.

An insurance claims manage determines how much to pay someone following a covered incident.
An insurance claims manage determines how much to pay someone following a covered incident.

In the case of a delay, this is usually because the insurance claims manager has reason to believe there may be fraud being perpetrated. This most often happens in cases of automobile insurance and life insurance. These have a greater potential for fraud simply because some claims may be hard to verify. In such cases, the delay is normally due to the fact the insurance company wants to conduct its own investigation into the validity of a claim. If, at the end of the investigation, no substantial evidence of fraud can be found, the claim will likely be approved.

Insurance claims managers may read over accident reports to determine fault.
Insurance claims managers may read over accident reports to determine fault.

The process to become an insurance claims manager normally involves getting a Bachelor's degree at a minimum. Most of those interested in the insurance field focus on business, business administration or finance. These are subjects generally related directly to the insurance field, and also provide a good background for work in other areas as well. It may also be possible for an insurance agent, with or without a college degree, to move into the position of a claims manager.

Health insurance claims often involve pre-approvals that must be done in the clinic before a procedure can be covered.
Health insurance claims often involve pre-approvals that must be done in the clinic before a procedure can be covered.

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