Claims Examiner Interview Questions

The goal for a successful interview for a Claims Examiner is for the candidate to demonstrate their expertise in reviewing insurance claims, assessing the authenticity of the claim, and interpreting insurance policies accurately to ensure timely and accurate claim settlements.

Situational interview questions

• You’ve received a claim that seems to be missing some crucial information. What steps do you take to obtain the missing information and resolve the claim?
• You come across a claims submission that seems suspicious or potentially fraudulent. How do you investigate the potential fraud and report your findings to your superiors?
• A claim has been submitted for damages that appear to be related to pre-existing conditions. How do you review the claim to determine the extent of coverage, if any, that the policyholder is entitled to?
• A complex claim has been submitted that involves multiple parties and several layers of coverage. What steps do you take to ensure that all parties receive proper coverage and that the claim is resolved fairly and efficiently?
• A policyholder has submitted a claim that involves confidential medical information. How do you handle this information while still ensuring that the claim is processed accurately and efficiently?

Soft skills interview questions

• Can you give me an example of a time when you had to handle a difficult customer? How did you handle the situation and what was the outcome?
• How do you handle stressful situations and manage your workload effectively? Can you give me an example of a time when you accomplished this?
• Have you ever faced a conflict with a coworker? How did you handle the situation and what did you learn from it?
• Can you tell me about a time when you had to adapt to a change in a work process or policy? How did you handle the change and what was the outcome?
• How do you prioritize your tasks and ensure that deadlines are met? Can you give me an example of a time when you had to manage multiple deadlines at the same time?

Role-specific interview questions

• Can you explain the difference between a pre-existing condition and an exclusion in an insurance policy?
• What steps do you take to investigate and analyze a complex insurance claim?
• How do you ensure compliance with industry regulations and company policies when processing claims?
• Can you discuss your experience with medical billing codes and terminology?
• What process do you follow to review and respond to customer appeals or complaints related to their claims?

STAR interview questions

1. Can you describe a situation where you had to investigate a complex insurance claim as a Claims Examiner?

– Situation: Investigating a complex insurance claim

– Task: Assigned responsibility to investigate and verify the claim

– Action: Dug deeper to get all the required information, used various resources and consulted with witnesses if necessary, and followed the company’s policies and procedures

– Result: Successfully determined the claim’s legitimacy.

2. Could you share an example where you had to calculate the exact settlement amount for a disputed claim as a Claims Examiner?

– Situation: Calculating the exact settlement amount for a disputed claim

– Task: Assigned the responsibility to determine the accurate amount

– Action: Careful investigation and analysis, researched the applicable laws and policies, and made a fair settlement offer after negotiation with the parties involved.

– Result: Successfully settled the dispute, and resolved the claim.

3. Tell me about a situation where you dealt with an unhappy claimant as a Claims Examiner?

– Situation: Dealing with an unhappy claimant

– Task: Assigned the responsibility to handle and resolve the complaint

– Action: Listened to the claimant’s complaint, investigated the issue fairly, explained the cause of the problem, apologised for any mistakes or misunderstanding, and offered a fair resolution, then ensured compliance with the company policies

– Result: Successful resolution of the complaint, restored the claimant’s trust in the company.

4. Could you described a time when you identified fraudulent activity as a Claims Examiner?

– Situation: Identifying fraudulent activity

– Task: Assigned the responsibility to verify the legitimate nature of the claim

– Action: Conducted a thorough investigation, scrutinized provided evidence, and consulted with experts if necessary, then used the company’s policies and guidelines to objectively assess the validity of the claim.

– Result: Successfully identified fraudulent activities in a claim and prevented the company’s loss.

5. Could you share an example where you had to perform a comprehensive review of a claim file as a Claims Examiner?

– Situation: Perform a comprehensive review of a claim file

– Task: Assigned the responsibility to review the entire claim file and verify the legitimacy of the claim

– Action: Examined the claim’s history, reviewed the provided evidence, communicated with the relevant parties, analysed the adjuster’s decision, and compared the claim to company policies and standards.

– Result: Successfully assessed the legitimacy of the claim and made informed decisions regarding the settlement.