Insurance claims are those that are processed by an insurance claims examiner. The purpose of an insurance claim is to be able to retrieve compensation for a monetary loss you suffer that is covered under your insurance policy. To be succinct after you file your insurance claim the claims examiner is going to either deny or approve your claim.

Types of Claims and Fraud Assessed

The examiner looks at claims validity and makes sure that the loss is actually covered under the policy. Additionally, the examiner is going to look for any indication of a potentially fraudulent claim. Through both company guidelines and their diagnostic skill they will be able to determine whether or not a claim should be denied or approved for payment.

Claims examiners will identify such things as:

• Healthcare fraud
• Bankruptcy fraud
• Insurance fraud
• Money laundering
• Consumer fraud

The types of claims examiners are vast and there is need for all kinds of examiners to be able to identify any fraudulent activity. By recognizing fraud companies will save money and their customers will save money in kind.

Claims Investigation

The claims examiner is the person that bears the responsibility of finding if the claim that was filed is one that is valid and has the accountability of determining whether or not the person that filed the claim has furnished all of the and the correct information. The claims examiner is trained to be able to identify those individuals that really need help from the ones that want to misuse, abuse and/or cheat the system.

Claims Examiner Employment Opportunities

There are many companies that are in need of practiced candidates to join their team. One of the biggest subsections is those areas of insurance and workers compensation.

The claims examiner is one that is responsible to help keep costs down through an awareness of the companies policies and make the determination on whether or not the claim is valid and should be rewarded. A claims examiner needs to have a thorough knowledge of their field not just in examining claims.

For instance, if the examiner has a job within a medical insurance company they must understand the differences and nuances of the different medical illnesses and conditions and be able to tell the difference between crucial and non substantive medical records. Additionally, they must have the knowhow and education of the varying physical conditions or ailments so that the claim can be legitimized or denied.

Asset Misappropriation

Finally, there are some cases where the claims examiner will be responsible for identification of misappropriation of assets in a company. The justice system will sometimes use claims examiners to investigate deceptive business practices and to investigate companies either big or small. Enron is a good example of when claims examiners would be used to investigate fraud, and they were in fact used throughout the investigative process for their keen knowledge on the situational aspects.

Many of the industries claim examiners are essential with their contributions to prevention policies when it comes to fraud claims within the industry as well as the establishment of both ethics programs and the guidelines therein that will either help to prevent or at least reduce fraud risk.