An insurance claims manager processes claims, reviews policies, and determines if benefits are payable. They may deny or delay claims if proper procedures are not followed or if fraud is suspected. A bachelor’s degree in business, administration, or finance is typically required.
An insurance claims manager is an individual who processes claims for claims, responds to any questions about claims, and escalates concerns to a supervisor or investigator. The claims approval process may be slightly different depending on the product and insurance company. For example, a life insurance product may simply require a death certificate to process a claim. Health insurance claims can be much more complicated, involving consultation and treatment pre-approvals.
Upon entry of a claim, an insurance claims manager, also known as an insurance claims adjuster, will review the specific policy in question. The manager will compare the nature of the claim to what the policy covers. If there is a match or partial, a full or partial benefit may be payable. For example, if a medical procedure is covered but the insured person uses an out-of-network physician, only part of the claim may be paid. The patient is responsible for the rest.
There can be many occasions when a claim is delayed or denied altogether. This can happen when a claims manager believes that the proper procedures for making a claim have not been followed as outlined in the insurance contract. In such cases, there may be an appeals procedure available to the policyholder. The claims manager may be required to file a report detailing exactly why the claim was delayed or denied.
In the case of a delay, this is usually because the claims manager has reason to believe that fraud may have been committed. This happens most often in cases of auto insurance and life insurance. They have a greater potential for fraud simply because some claims can be difficult to verify. In these cases, the delay is usually due to the insurance company wanting to conduct its own investigation into the validity of a claim. If, at the end of the investigation, no substantial evidence of fraud is found, the claim will likely be approved.
The process to become an insurance claims manager typically involves obtaining a bachelor’s degree at a minimum. Most people interested in the field of insurance are focused on business, business administration, or finance. These are subjects that generally relate directly to the field of insurance and also provide a good basis for work in other areas. It may also be possible for an insurance agent, with or without a college degree, to move into the position of claims manager.
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