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

The role of a claims adjuster in health insurance primarily involves investigating and evaluating the details surrounding an insurance claim. This professional assesses whether the claim is valid and determines the insurer's liability based on the information gathered. They examine medical records, review treatment plans, and communicate with healthcare providers to make informed decisions regarding the approval or denial of claims. This process ensures that claims are handled fairly and in accordance with the terms of the insurance policy.

In contrast, the other roles listed serve different functions within the insurance landscape. An agent is focused on selling policies and may not be involved in the claims process at all. A regulatory officer would typically be engaged in overseeing compliance within the industry rather than dealing with individual claims. Meanwhile, a healthcare professional who assesses treatment necessity operates in the medical field, evaluating the appropriateness of treatments rather than handling insurance claims directly. Understanding the specific function of a claims adjuster is crucial in grasping how health insurance operates and how claims are processed.