Top 20 Interview Questions & Answers for Claims Auditor Roles – 2025

Preparing for a claims auditor job interview? This guide provides a list of essential questions and answers that will help you showcase your technical expertise, analytical skills, and experience in the insurance industry. Whether you’re applying for a role as a medical claims auditor, auto claims auditor, or general claims auditor, these questions cover all key areas of the job.

General Questions

• 1. Can you tell us about your experience as a claims auditor?
  

  As a claims auditor, I have X years of experience in reviewing and analyzing insurance claims to ensure accuracy and compliance with company policies and industry regulations. I have worked with various types of claims, including medical, auto, and property, and have a thorough understanding of the claim review process.

• 2. How do you stay updated with changes in the insurance industry and regulations?
  

  I regularly attend industry conferences, participate in online forums, and network with other claims auditors to stay informed about any changes in regulations or best practices. I also make it a point to read industry publications and attend company training sessions to stay updated.

• 3. How do you prioritize your workload and meet tight deadlines?
  

  I have excellent time management skills and am able to prioritize my workload based on urgency and importance. I also communicate with my team and supervisors to ensure that we are all aligned on deadlines and work together to meet them.

• 4. Can you walk us through your claim review process?
  

  First, I review the claim for accuracy and completeness, ensuring all necessary documents are attached. Then, I verify the information with the insured party and any involved parties. I also look for any discrepancies or red flags that may require further investigation. Finally, I make a determination based on my analysis and document my findings in a report.

• 5. How do you handle a situation where you discover fraudulent activity in a claim?
  

  If I discover fraudulent activity, I first gather evidence and document it. Then, I escalate the issue to my supervisor and work with our fraud investigation team to ensure that proper action is taken. I also make sure to follow all company protocols and report the findings to the appropriate authorities.

Technical Skills & Experience

• 6. What are the key factors you consider when reviewing a medical insurance claim?
  

  I consider the patient's medical history, the prescribed treatment, and any previous claims for similar treatments. I also verify that the service was medically necessary and in line with industry standards and regulations.

• 7. How do you ensure all claims are compliant with state and federal laws?
  

  I stay updated with all state and federal regulations and ensure that all claims are reviewed against these laws. I also conduct regular audits to identify any potential compliance issues and proactively address them.

• 8. Can you give an example of a complex claim you have successfully reviewed?
  

  I once reviewed a medical insurance claim for a rare procedure that required extensive documentation. I carefully evaluated all medical records and consulted with medical experts to ensure the treatment was necessary and in line with industry standards. I also worked with the claims adjuster to negotiate a fair settlement for the insured party.

• 9. How do you handle a high volume of claims while maintaining accuracy?
  

  I have developed a system for organizing and prioritizing my workload, which allows me to review a high volume of claims without sacrificing accuracy. I also collaborate with my team to ensure efficient and timely processing of claims.

• 10. How do you handle a situation where you disagree with a decision made by the claims adjuster?
  

  If I disagree with a decision made by the claims adjuster, I first review all documents and evidence to support my disagreement. Then, I discuss my concerns with my supervisor and provide possible alternatives or solutions. Ultimately, I understand that the final decision rests with the claims adjuster and I respect their authority.

Behavioral Questions

• 11. How do you handle working with difficult or frustrated insured parties?
  

  In my previous experience, I have encountered difficult or frustrated insured parties. To handle these situations, I maintain a calm and empathetic demeanor and actively listen to their concerns. I also make sure to explain the claims process and endeavor to find a satisfactory resolution for all parties involved.

• 12. Can you describe a time when you had to make a difficult decision during a claim review?
  

  I once had to make a difficult decision to deny a claim due to insufficient evidence of an insured party's loss. I thoroughly reviewed all available information and consulted with my team to ensure I was making an informed decision. I also communicated the reasons for the denial clearly and professionally to the insured party.

• 13. How do you handle a situation where you made a mistake in a claim review?
  

  If I realize I made a mistake in a claim review, I immediately inform my supervisor and take steps to correct the error. I also communicate with all parties involved and make sure that the mistake does not impact the overall claims process or the insured party.

• 14. How do you handle competing priorities or urgent tasks during a claim review?
  

  In such situations, I prioritize based on urgency and importance and make sure to communicate with my team and supervisor. I also work efficiently and seek assistance if needed to ensure that all tasks are completed accurately and within the given timeframe.

• 15. Can you walk us through a time when you had to think outside the box to solve a problem during a claim review?
  

  In a past claim review, I encountered a unique case where the insured party's documentation did not match the standard procedure for their treatment. I consulted with medical experts and researched industry guidelines to understand the situation in-depth and came up with a solution that was fair to all parties involved.

Situational Questions

• 16. How would you handle a situation where you are unable to reach the insured party or involved parties for additional information?
  

  In such a scenario, I would first send a written request for the necessary information and follow up with a reminder call or email. If I still do not receive the information, I would escalate the issue to my supervisor and take appropriate actions, such as closing the claim or seeking legal advice if necessary.

• 17. How would you handle a dispute between an insurance company and a third-party provider regarding a claim?
  

  In a situation like this, I would review the insurance policy and contract agreements to understand the responsibilities of each party. Then, I would work with both parties to negotiate a resolution that is fair and in line with the policy and contract terms.

• 18. How would you handle a situation where you suspect an insured party may be exaggerating their injury or loss?
  

  If I have reason to suspect an insured party is exaggerating their claim, I would review all available evidence and consult with my team to determine the next steps. If necessary, I would involve our fraud investigation team and escalate the issue to my supervisor.

• 19. How would you handle a situation where the insured party is unable to provide documentation for their claim due to extenuating circumstances?
  

  In such a situation, I would show empathy and understanding and work with the insured party to find alternative forms of documentation, such as witness statements or medical records, if applicable. If there is no other way to obtain the necessary documentation, I would escalate the issue to my supervisor for further guidance.

• 20. How would you handle a situation where you discover a mistake in the claim review process that may affect multiple claims?
  

  If I discover a mistake or error that may impact multiple claims, I would immediately inform my supervisor and take appropriate steps to correct the mistake. I would also communicate with all parties affected and make sure to implement measures to prevent similar mistakes in the future.