A claims representative is responsible for providing customer service, processing claims requests and resolving problems. These representatives can be found in multiple industries but are most commonly found in the service sector. Potential employers include government benefit agencies and insurance companies.
The claims representative is the first point of contact for customers who need to file a claim. The purpose of a claim is to request reimbursement of a payment or to access benefits paid for through an insurance program. Clients make regular payments to obtain insurance or benefit coverage. When a related expense occurs, he or she contacts the insurance company to make a claim against that policy.
Customer service includes answering incoming phone calls, emails and letters. The claims representative reviews the information provided, accesses the client's policy with the company and determines if the expense claimed is covered. If there is any missing information or if further details are required, the representative initiates contact with the client to resolve these issues.
Claims representatives are responsible for entering the data into the computer system or reviewing the claim and making an initial assessment. In many cases, the review is designed to spot processing errors or missing information. After careful review, the representative can approve, deny or escalate a claim. The escalation process typically sends the claim to a supervisor who can review the claim in more detail and make a decision.
The types of problems that a claims representative is responsible for solving include delays in payment processing, customer account renewal issues, modifying account information and fielding complaints. In many cases, the representative works closely with the various departments to resolve the problem on behalf of the client. Situations that cannot be resolved in a specific time frame are escalated to a supervisor.
The work environment for a person in this position is a standard office cubical, complete with a computer and telephone. He or she sits at a desk and works on the computer the vast majority of the time. There is very little direct physical contact with clients in this role.
In order to become a claims representative, a combination of education and related experience is required. The actual level of training varies by industry. For example, an insurance company will provide detailed training to all claims representatives but might also require successful completion of a post-secondary program in business or customer service. Most government agencies prefer candidates with at least one year of training, but they also provide a detailed training program.