A claims process can look deceptively simple on paper. The notice comes in, documents are collected, claim is reviewed and payment goes out. But spend any amount of time with the people actually examining those claims, and the boxes on the process map start looking very different.
During a recent Benekiva Claimversation, we brought together four former examiners who spent years and even decades in claims to talk about what the examiner role actually looks like. The conversation was a reminder of just how much knowledge, judgment, investigation, communication, and decision-making sits underneath a workflow that can appear straightforward from the outside.
A claims examiner rarely has the luxury of looking at a single document, applying a rule, and moving on. One claim may require understanding policy provisions, beneficiary designations, state requirements, trusts, estates, wills, tax implications, historical records, and documentation that was made decades ago. Another may require contact with police departments, coroners, agents, attorneys, or family members. Examiners have to read old handwriting, investigate conflicting information, and determine what to do when the circumstances in front of them do not fit neatly into the expected process.
As one panelist described it, examiners have to know a little about a lot. The breadth of knowledge is easy to underestimate when we reduce claims work to throughput, cycle time, or the number of tasks completed. While those metrics matter – examiners always strive to pay out the right benefit to the right party as quickly as possible – they don’t capture all of the decisions happening inside the work itself.
They also don’t capture the systems examiners must navigate to make those decisions. Panelists recalled environments where a single examiner might work across several administration systems and multiple claims systems depending on the product involved. Answering what sounds like a simple question from a claimant could require moving between applications just to find the policy, understand its status, and piece together the right answer. In other environments, examiners were updating spreadsheets, manually creating correspondence, re-entering the same information into multiple systems, or calculating information that could have been handled elsewhere in the process.
Each of those processes takes time, attention and mental load that could otherwise be spent on the parts of the job that actually require expertise and the human touch, such as talking with claimants.
This view into an examiner’s world brings an important topic front and center when it comes to claim modernization: the goal shouldn’t be to just automate more of the claims, but rather to understand where examiners spend cognitive effort that provides little value versus where that same examiner's judgment is essential. If information has already been entered once, why should someone have to enter it again? If a letter follows an established pattern, why should an examiner build it manually every time? If a system can bring relevant information together instead of forcing someone to search across five places, that is meaningful automation.
On the flip side, when asked what technology shouldn’t fully automate, the panel responded with decision-driven areas like claim denials or even outgoing communications. The concerns were rooted in a recognition that insurance claims contain exceptions, context, and consequences. A piece of correspondence may be technically accurate, but adding another sentence might give it the human touch and care these types of claims require. An automated recommendation can be extraordinarily useful, but consequential decisions still need the right level of human judgment and oversight.
That is why one of the simplest recommendations from the conversation may also be one of the most important: spend time with the people doing the work. Dashboards can tell leaders if targets are met, but they can’t show what it takes to meet those targets. A process map can document the intended workflow, but can’t cover every workaround, duplicate entry, judgment call, or system switch happening along the way.
One panelist suggested that leaders spend hours, or ideally a full day, shadowing an examiner, because you won’t see all of the friction in a half hour. Watch how many systems they open. Listen to the questions they receive. Notice where they pause to investigate something unusual. See which activities require expertise and which simply require persistence.
That perspective is vital when you’re redesigning a process or trying to introduce new technology. Claims examiners know where the friction lives because they live it every single day. They know which steps are unnecessary, which information is difficult to find, how often each exception happens, and where seemingly minor decisions create additional work downstream. They also know where removing a human decision can introduce a very different kind of risk. The people closest to the work must be part of understanding the problem before a solution is chosen.
The better question for claims modernization isn’t, “How much of this can we automate?” but, “What does the examiner need to spend their time thinking about?”
An examiner's cup is usually overflowing with all of the system work, decisions, and empathy they must carry. If you can take away the duplicate entry, take out a few systems so they have less context switching, give them better tools for calculations and investigations, you are reducing the load in their cup so that they have more to pour out to the claimants they serve every day. Examiners will be less burned out and claimants will get a better experience, leading to a better claims process for everyone.
