What is the role of a claims adjuster in health insurance?

The role of a claims adjuster in health insurance primarily revolves around the evaluation and assessment of insurance claims to determine the insurer's liability. This includes reviewing the details of the claim, such as the medical documentation, treatment history, and policy coverage, to make informed decisions about the validity of the claim.

Claims adjusters investigate claims to ensure that they meet the requirements of the policy and comply with regulations. Their assessments are critical in determining how much the insurance company should pay to the policyholder or healthcare provider for medical services rendered. This process involves collaboration with medical professionals when necessary, analyzing the terms of the insurance policy, and adhering to any relevant laws or regulations.

Besides, a claims adjuster is not directly involved in selling insurance policies, assessing network providers, or consulting on wellness programs, which are roles designated for other professionals in the insurance and healthcare industries. Hence, their primary responsibility focuses on claims assessment and management.