Claims Specialist Job Description
Claims specialist
provides support (or coverage) for the Insurance Claims Representative(s) on Auto & General liability claim intake/initial processing as needed or as required.
Claims Specialist Duties & Responsibilities
To write an effective claims specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included claims specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Obtain information necessary for claim to be established in the claims system
Handle all inquiries from claimant, insured or medical provider regarding the status of a claim
Comply with all rules, regulations and laws regarding the payment of medical claim
Identify viable payer(s) and obtain all necessary documentation to properly process the claim for payment including, when applicable, IBs, UBs, Medical Records, POs, EOBs when necessary
Correspond with patients, policyholders, insurers, police, witnesses or other parties involved in the accident, and attorneys to obtain additional, relevant information to support the claim for monies owed
Use the operating systems (FACS, SSI ) to perform timely processing and follow up on every claim from initial placement thru resolution
Enter new flood insurance claims and claim payments, review of all documentation including adjuster reports, engineer reports, underwriting alerts, inputting concise yet sufficient file documentation
Researching billing exceptions and issues in databases
Performing related data entry in proprietary applications
Processing EDI files as required
Claims Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Claims Specialist
List any licenses or certifications required by the position: CCP, UW, ARM, FML, FEMA
Education for Claims Specialist
Typically a job would require a certain level of education.
Employers hiring for the claims specialist job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and High School Degree in Education, Graduate, Business, Graduate Education, High School Education, Finance, Associates, Management, Technical, Law
Skills for Claims Specialist
Desired skills for claims specialist include:
Legal liability
Claim
Entire claims administration
Case management and cost containment solution as applicable to Workers’ Compensation
Medical terminology
Insurance industry
But not mandatory
Insurance coverage and medical terminology helpful
Claims and the insurance legal and regulatory environment
Claim and disability duration
Desired experience for claims specialist includes:
Research and develop appeals for denied claims
Confirm coverage in system and verifies that both team and individual are sanctioned
Investigate to verify that injury occurred while claimant was participating in a covered event
Analyze medical bills for causal relationship to the accident/injury
Review Explanation of Benefits from primary insurance to determine obligation under our policy
If appropriate, re-price medical bills through the PPO network and/or use system to see if procedures were reasonable and customary to establish proper payment
Claims Specialist Examples
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Claims Specialist Job Description
Job Description Example
Our company is looking to fill the role of claims specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims specialist
- Prepare plan for investigation of claim, contact doctors/ hospitals or other persons/ organizations or check with client’s family or neighbor to verify information to make claims decisions
- Issue payment to medical providers
- Process/move and maintain claims within the claims workflow and archival systems
- Handles difficult phone calls
- Composes special correspondence
- Works on special projects and tasks as assigned
- Verifies travel insurance coverage utilizing various methods , computer, fax, manifest, e-mail or telephone
- Formulates DOI/BBB complaint responses, addressing all concerns and gather all necessary documents to file a complete and timely response meeting all state requirements
- Work with the AAH compliance area Claims Compliance on any research needed of applicable laws and regulations
- Has extensive experience of handling claims of a complex nature
Qualifications for claims specialist
- Investigating and resolving claims including confirmation that the customer's statement and actions are accurate and appropriate in accordance with the customer contracts
- Analyzing SAP data for reported shortage and damage claims to recognize trends, weaknesses, and opportunities to lower risk and improve process
- Performing weekly review of deduction report associated with transportation claims and expired returns
- Analyzing each deduction to confirm validity of deduction
- Identifying source of credit processing delay
- Working with direct and/or indirect customers third party processors to verify return details and ensure appropriate credit is issued
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Claims Specialist Job Description
Job Description Example
Our growing company is hiring for a claims specialist. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claims specialist
- Understanding of FSA, HRA and HSA plans
- Serve as a resource of help to other claims specialists who need assistance and have questions on their cases
- Claims will be processed within established company and client guidelines and must be reviewed, based on authority level, by the Claims Supervisor and/or Director prior to payment
- Oversee processes casualty claims management
- Subject matter expert on Worker’s Compensation and property damage/bodily injury claims
- Participate in planning processes and promote best practices
- Conduct trainings with employees, managers and HR Business Partners on departmental process and obligations
- Act as liaison between departments on workers compensation, auto and general liability issues, Employee and Labor Relations, General Counsel, Benefits and external vendors
- Serve as liaison with disability claims managers and workers compensation claims managers and nurse case managers to manage the job analysis process and return to work program with third party vendors
- Ensures timely and accurate communications, consistency and accuracy of benefit coverage and service delivery from all parties involved in each case
Qualifications for claims specialist
- Strong data entry, 10-key and P.C
- Evaluates return to work situations with HR and Operations
- Address and resolve escalated and highly complex, sensitive issues and inquires for all constituencies including recommending medical separation for long term cases
- Excellent facilitation and oral and written communication skills
- Proficient in managing multiple sources of data and integrity
- One year of auto insurance claims experience
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Claims Specialist Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of claims specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims specialist
- Reviews and evaluates a complete claim file in order to prepare and file proper arbitration filings with strong arguments and proper evidence
- Evaluate claim for potential fraud and work with Special Investigations Unit
- Timely analyze information in order to evaluate assigned claims to determine the extent of loss, taking into consideration contributory or comparative negligence
- Handles property/inland marine claims for assigned region with availability to assist as needed in all other regions
- Evaluates and settles property-related damages (primarily) between $25,000 and $100,000 (aggregate)
- Handles typical Business Income losses
- This position will join the LLU as part of the corporate catastrophe team
- Responsible for all coverage determinations, negotiations, reserving and settlement within established authority
- Provides coverage and/or estimating assistance to regional CMS’ as may be required by management
- Responds to all legal, regulatory or appeals situations or requests
Qualifications for claims specialist
- Relevant professional qualification (ACII/FCII/CILA)
- Two – three years of claims operational experience
- Minimum 1-year previous customer service or collections experience required, call center experience is a plus
- Strong attention to detail and results oriented
- Strong computer knowledge is required including word processing (MS Office, Outlook, Excel)
- Knowledge of State Medicaid and Federal Disability programs is a plus
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Claims Specialist Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of claims specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims specialist
- Identifies information and resources needed to adjudicate claim
- Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator)
- Requests complaint failure investigations
- Direct the TPA to Investigate the claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, insureds, witnesses and others having pertinent information
- Evaluate, negotiate and settle both non-litigated and litigated claims within delegated authority
- Assume responsibility for complex injury claims, including soft tissue, serious fractures, fatalities, disfigurements
- Plan and conduct investigations (including but not limited to interviewing parties involved, collecting and evaluating documentation and securing evidence and protecting the chain-of-custody, determine inspection needs, order police reports, scene investigation, take witness statements, review material damage photos, order medical reports, ) to analyze coverage, determine liability, compensability, and extent of damages
- Create a dynamic and stimulating work environment for all colleagues in the unit
- Ensure that people development, productivity and quality output are on top of the agenda
- Organise the workflow of the unit in order to achieve the required level of service to the clients
Qualifications for claims specialist
- Knowledge of hospital computer software is a plus (Epic, Cerner, Meditech, Siemens)
- Proficient in use of CLAIMSTATION, MBPA and Claims Outcome Advisor
- Must have the ability to work varying shifts
- Prefer 5 years claims experience, thorough knowledge of Commercial and Personal Lines coverages and computer-based damage estimating
- Must possess certification(s) identified as acceptable in Selective’s Claims Certification Policy or willingness to achieve certification
- Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field preferred
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Claims Specialist Job Description
Job Description Example
Our growing company is looking to fill the role of claims specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims specialist
- Monitor and provide internal clients with specific, objective and practical claim guidance
- Demonstrate strong written communication skills, including the ability to articulate complex coverage and claim facts with clarity and in a way that can be understood by non-insurance professionals
- Review and provide guidance on claim reserve accuracy
- Take final responsibility for delicate files and projects handled within the unit
- Foster working together between teams within Madrid with those teams in other locations
- Gather the appropriate company and public records, , police, fire reports, , as needed
- Shares knowledge of current regulations with staff
- Obtains and analyzing a wide variety of applicable documentation related to assigned claims, some of which may include, , ISO reports, fire reports, police reports, cause & origin reports, medical reports, engineer reports, written estimates, witness accounts
- Supervise implementation of Claims Officers according to turn around time set
- Report to Deparment Head the status of claims settlement
Qualifications for claims specialist
- Experience with litigated claims having multiple defendants and complex, 3rd-party contract elements required
- 5-7 years’ experience with Worker’s Comp Coverage
- Knowledge and understanding of Return to Work program
- Proficiency in all Microsoft Office Programs, including Word, Excel
- Bachelor’s degree and/or 2-3 years claims experience
- Possess strong analytical skills and sound judgment