Claims analysts evaluate insurance claims for eligibility and may work in various industries. They require attention to detail and industry knowledge. They check claims for completeness, request additional information, and determine eligibility. Denials can be appealed. Training involves obtaining a certificate or diploma.
A claims analyst evaluates claims submitted to insurance companies to determine whether or not the claims meet the company’s eligibility standards. People in this position may also work for customer complaint and fraud departments in companies such as banks and large retailers, dealing with customer complaints. In all cases, claims analysts need to have an excellent eye for detail and extensive knowledge of the industry they work in to ensure that they provide an adequate level of customer service.
One of the most classic fields of work for a claims analyst is the health insurance industry. They may also handle car insurance, life insurance, home insurance, warranty claims, and other situations where a customer or consumer submits a claim to a company for payment or other action. Training for this job usually involves obtaining a certificate or diploma in the field in which a claims analyst intends to work, supported by the accreditation procedure at the office and the specific procedures involved in processing claims and claims.
When a claim is submitted to a company, the claims analyst first checks it to determine whether or not the claim is complete. He or she may request additional information such as documentation, test results and other material that may be relevant to the claim. After collecting all the necessary information, the analyst can determine whether or not the claim is eligible for payment and send a payment or denial letter, depending on the circumstances.
A claims analyst usually works under the supervision of another person, such as a senior claims analyst who heads a department, a collections specialist, or a more general administrator. These professionals are usually trained to adhere to company policy as much as possible when dealing with complaints and err on the side of denial rather than standard acceptance of complaints. This is designed to reduce company expenses and reduce the risk of fraudulent, incomplete or marginally eligible claims being paid.
When people receive a denial letter, they can choose to appeal the decision by requesting further review along with the reasons why the claim was denied. This review may be performed by another claims analyst or by someone hired specifically to handle appeals. When appealing claims, it helps to get as much information about company policy and how the complaint was handled as possible, to look for potential areas of contention or weaknesses that could be used to challenge the denial.
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