Detailed Guide forClaims Adjusters, Examiners, and Investigators in California
May also be called: Appraisers; Claims Agents; Claims Analysts; Claims Representatives; Claims Specialists; Customer Care Specialists; Field Adjusters; Health Insurance Adjusters; Insurance Appraisers; Insurance Auditors; Litigation Examiners; Workers' Compensation Examiners
What Would I Do?
Individuals and businesses purchase insurance policies for protection against financial loss from injury, illness, death, property damage, or liability for harm or loss to other people. Claims Adjusters, Examiners, and Investigators act as a mediator between the claimant and the company. They generally process claims, interpret or explain policies, and resolve billing disputes. They also calculate benefit payments and approve payment of claims within a certain monetary limit. Claims Adjusters, Examiners, and Investigators correspond with or interview medical specialists, agents, witnesses, or claimants to compile information. They also confer with legal counsel on claims requiring litigation.
When a policyholder submits a claim for a loss, Adjusters and Examiners determine whether the client’s policy covers the loss and the amount of the loss covered. Then they evaluate the facts and write up the settlements. Although many Adjusters, Examiners, and Investigators have overlapping functions and may even perform the same tasks, the insurance industry generally assigns specific roles to each of these claims workers.
Adjusters specialize by type of insurance: homeowner, automotive damage, bodily injury, business losses, or workers’ compensation. Most work for insurance companies or independent adjusting firms, processing loss claims and contacting clients either in person, by telephone, or mail to obtain details about an accident or property loss. Some work outdoors in the field where they inspect and appraise vehicle or property damage, interview witnesses, calculate repair costs, and perform routine investigations. Public Adjusters do not work for insurance companies; they represent and work for the best interests of the insured or claimant. They help their clients prepare and present claims to insurance companies and negotiate for a fair settlement.
Adjusters often use laptop computers to download forms and files from insurance company databases. They also input information about the damage directly into their computers, where software programs produce estimates of the damage on standard forms. Adjusters use cell phones and personal digital assistants (PDAs). Digital cameras are also used to take photographs of property damage, which can be e-mailed directly to the insurance company via the Internet.
Most Examiners work for life or health insurance companies and usually concentrate on hospital, dental, or prescription drug claims. They review health-related claims to determine if the charges are reasonable and in line with the medical diagnosis. Then, Examiners will make decisions to authorize payments or refer the claim to an Investigator if there is a suspicion of fraud. Examiners within property and casualty insurance firms may have duties similar to those of an Adjuster, but often their primary job is to review the claims submitted in order to ensure that proper guidelines have been followed. They may assist Adjusters with complicated claims or when a disaster strikes.
When Insurance Adjusters or Examiners suspect insurance fraud, they refer the claim to an Investigator. Investigators conduct a thorough investigation to make a determination whether the claim is valid or should be referred to law enforcement authorities. They usually start with a database search to obtain background information on claimants and witnesses. They also check the history of prior insurance claims filed by the claimant. Investigators may record interviews with witnesses. They may also conduct surveillance activities such as observing workers’ compensation claimants for activities inconsistent with their claim. Investigators and Examiners may use analytical or scientific software, as well as document management software, when working with insurance claims.
Important Tasks and Related Skills
Each task below is matched to a sample skill required to carry out the task.
|View the skill definitions|
|Task||Skill Used in this Task|
|Interview or correspond with claimant and witnesses, consult police and hospital records, and inspect property damage to determine extent of liability.||Customer and Personal Service|
|Investigate and assess damage to property.||Critical Thinking|
|Examine claims forms and other records to determine insurance coverage.||Complex Problem Solving|
|Analyze information gathered by investigation, and report findings and recommendations.||Inductive Reasoning|
|Investigate, evaluate and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.||Judgment and Decision Making|
|Pay and process claims within designated authority level.||Information Ordering|
|Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.||Law and Government|
|Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.||Clerical|
Below is a definition for each skill.
|View the tasks to skills list|
|Customer and Personal Service||Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.|
|Critical Thinking||Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.|
|Complex Problem Solving||Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.|
|Inductive Reasoning||The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).|
|Judgment and Decision Making||Considering the relative costs and benefits of potential actions to choose the most appropriate one.|
|Information Ordering||The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).|
|Law and Government||Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.|
|Clerical||Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.|
Working environments of Claims Adjusters, Examiners, and Investigators vary greatly. Claims Adjusters may have irregular schedules and work more than 40 hours per week. They often arrange their work schedules to accommodate evening and weekend appointments and can be called into work in the event of an emergency. Many Adjusters may work in offices for only a few hours per week, usually to gather their assignments for the day. Others may conduct business from their home or automobile. They may spend the majority of their day inspecting damaged buildings and automobiles. They must use caution when working in damaged buildings with hazards, such as weak structures and collapsed roofs and floors. Traveling to claim sites may be necessary to evaluate the scene of an accident or natural disaster, such as a flood.
Examiners working for health or life insurance companies work a standard 5-day, 40-hour week in modern office buildings equipped with the latest office machines and computers. In contrast, Investigators often work irregular hours because of the need to conduct surveillance and contact people who are not available during normal working hours. Early morning, evening, and weekend work is common. Investigators spend some of their time in the office making telephone calls and conducting computer database searches. They spend much of their time outside the office interviewing clients and witnesses. The job can be stressful and hazardous at times because of potential conflicts with clients.
There has been little or no unionization of Claims Adjusters, Examiners, and Investigators. However, they may belong to organizations such as the Insurance Information Institute or the National Association of Health Underwriters.
Will This Job Fit Me?
The job of Claims Adjuster, Examiner, and Investigator will appeal to those who enjoy activities that involve starting up and carrying out projects, especially business ventures. Individuals considering this occupation should also like working with people and performing duties that are organized, clearly defined, and require accuracy and attention to detail. This occupation satisfies those with both enterprising and conventional interests. Enterprising occupations frequently involve persuading and leading people, making decisions, and taking risks for profit. People with enterprising interests generally prefer action rather than thought. Conventional occupations often involve working with data and details more than with ideas and following set procedures and routines where the lines of authority are clear.
What Wages and Benefits Can I Expect?
The median wage in 2016 for Claims Adjusters, Examiners, and Investigators in California is $70,550 annually, or $33.91 hourly. The median is the point at which half of the workers earn more and half earn less.
Claims Adjusters, Examiners, and Investigators generally receive sick leave, vacation, health insurance, group life, and pension plans. In addition, Adjusters who work in the field usually receive an expense account or the use of a company car as well as mileage reimbursement. Self-employed Adjusters, Examiners, and Investigators are responsible for purchasing their own insurance and retirement plans.
What is the Job Outlook?
Keen competition for Claims Adjuster, Examiner, and Investigator jobs is expected, especially in smaller, privately owned companies. Employment opportunities will continue to exist as these jobs are not easily automated. Increasingly, insurance companies provide business services through telephone call centers that offer extended business hours. Customers initially speak to customer service representatives who gather initial claim loss information and pass it along to an Adjuster or Examiner for further processing. Claim intake through call centers will allow Adjusters more time to examine claims.
Projections of Employment
In California, the number of Claims Adjusters, Examiners, and Investigators is expected to grow slower than average growth rate for all occupations. Jobs for Claims Adjusters, Examiners, and Investigators are expected to increase by 8.2 percent, or 2,600 jobs between 2012 and 2022.
|Estimated Employment and Projected Growth|
Claims Adjusters, Examiners, and Investigators
(Estimated Year-Projected Year)
Due to Net
|View Projected Growth for All Areas|
Annual Job Openings
In California, an average of 260 new job openings per year is expected for Claims Adjusters, Examiners, and Investigators, plus an additional 740 job openings due to net replacement needs, resulting in a total of 1,000 job openings.
|Estimated Average Annual Job Openings|
Claims Adjusters, Examiners, and Investigators
|Jobs From Growth||Jobs Due to|
|View Data for All Areas|
How Do I Qualify?
Education, Training, and Other Requirements
A high school diploma is typically the minimum requirement needed to obtain employment as a Claims Adjuster, Examiner, or Investigator. However, most employers prefer to hire college graduates or applicants who have some postsecondary or long-term on-the-job training. An individual who has a business or an accounting background could specialize in claims of financial loss due to faulty equipment or damage to merchandise. Training in architecture or engineering is helpful in adjusting industrial claims, such as those involving damage from fires or other accidents. A legal background can be beneficial to Adjusters handling workers’ compensation and product liability cases. A medical background is useful for those Examiners working on medical and life insurance claims.
Adjusters working for insurance companies must be licensed and have two years of certified experience in the adjusting field to meet pre-licensing requirements. Public Adjusters must complete a Public Insurance Adjuster Authorization Application. To apply for a license, applicants must:
- Complete an Individual Insurance Adjuster licensing application for an Insurance Adjuster (nonpublic), Public Insurance Adjuster, or an Interim Public Insurance Adjuster
- Take and successfully pass a licensing examination
- File a bond
- Obtain a fingerprint clearance
Adjusters and Examiners are usually required to have at least one year of claims or managed care experience. Since they often work closely with claimants, witnesses, and other insurance professionals, they must also be able to communicate effectively with others. Additional knowledge in business administration, business law, finance, economics, accounting, mathematics, and computer technology may be helpful.
Many employers prefer to hire Investigators with prior experience as law enforcement officers or private Investigators. Persistence, assertiveness, good communication skills, and the ability to deal with confrontation are important skills to employers.
Early Career Planning
High school students who are interested in this field should take classes in English, business, mathematics, and computers. Courses in public speaking, communication, and theater arts can help students who wish to learn how to communicate more effectively.
Work Study Programs
California offers Regional Occupational Programs (ROP) for Claims Adjusters, Examiners, and Investigators. To find an ROP program near you, go to the California Association of Regional Occupational Centers and Programs Web site.
Continuing education is not required; however, it is important that Claims Adjusters, Examiners, and Investigators remain knowledgeable because federal and State laws and court decisions affect how claims are handled or who is covered by insurance policies. For instance, Examiners working on life and health claims must be familiar with new medical procedures and prescription drugs. Those working on auto claims must be familiar with new car models and repair techniques. Claims Adjusters, Examiners, or Investigators may continue their education by attending classes or workshops.
Licensing and Certification
Insurance Adjusters, Public Insurance Adjusters, and Interim Public Insurance Adjusters must be licensed. Contact the agency that issues the license for additional information. Click on the license title below for details.
Claims Adjusters may hold an Associate in Claims certificate. Examiners working in life and health insurance industries often obtain voluntary certification to enhance their skills and employability. Educational programs, such as the Associate, Life, and Health Claims and the Fellow, Life, and Health Claims program allow life and health claim Examiners to obtain professional designation. For more information, go to the U.S. Department of Labor's Career InfoNet Web site and scroll down to "Career Tools." Click on "Certification Finder" and follow the instructions to locate certification programs.
Where Can I Find Training?
There are two ways to search for training information:
- Search by Field of Study to find what programs are available and what schools offer those programs. You may use keywords such as: Medical Claims Examiner, Banking and Financial Support Services, and Finance.
- Search by Training Provider to find schools by name, type of school, or location.
Contact the schools you are interested in to learn about the classes available, tuition and fees, and any prerequisite course work.
Where Would I Work?
The largest industries employing Claims Adjusters, Examiners, and Investigators are as follows:
|Industry Title||Percent of Total Employment for Occupation in California|
|Insurance Carriers ||35.0%|
|Insurance Agencies, Brokerages & Support ||24.5%|
|Federal Government ||14.7%|
|State Government ||8.4%|
|Management of Companies and Enterprises ||4.7%|
Finding a Job
Direct contact with local insurance company managers or agents remains one of the most effective job search methods. Applicants can also find employment opportunities through placement offices at colleges and universities. Those working within the industry may recommend an interested candidate for jobs. Newspaper classified ads and the Internet provide additional sources for job listings. Online job opening systems include JobCentral at www.jobcentral.com and CalJOBSSM at www.caljobs.ca.gov.
To find your nearest One-Stop Career Center, go to Service Locator. View the helpful job search tips for more resources. (requires Adobe Reader).
Yellow Page Headings
You can focus your local job search by checking employers listed online or in your local telephone directory. Below are some suggested headings where you might find employers of Claims Adjusters, Examiners, and Investigators.
- Insurance Claims Processing Services
- Insurance Inspections and Audits
Find Possible Employers
To locate a list of employers in your area, go to "Find Employers" on the Labor Market Information Web site:
- Select one of the top industries that employ the occupation. This will give you a list of employers in that industry in your area.
- Click on "View Filter Selections" to limit your list to specific cities or employer size.
- Click on an employer for the street address, telephone number, size of business, Web site, etc.
- Contact the employer for possible employment.
Where Could This Job Lead?
As Claims Adjusters, Examiners, and Investigators gain more experience, promotion often takes the form of assignments to larger, more complex claims. Furthermore, employees who demonstrate competence in claims work or administrative skills may be promoted to more responsible managerial or administrative jobs, such as claims manager. Others may elect to become self- employed by setting up their own independent adjusting firms.
Below is a list of occupations related to Claims Adjusters, Examiners, and Investigators with links to more information.
|Appraisers and Assessors of Real Estate||Profile|
|Detectives and Criminal Investigators||Guide|
|Insurance Appraisers, Auto Damage||Profile|
|Insurance Claims and Policy Processing Clerks||Profile|
|Title Examiners, Abstractors, and Searchers||Profile|
These links are provided for your convenience and do not constitute an endorsement by EDD.
For the Career Professional
The following codes are provided to assist counselors, job placement workers, or other career professionals.