Insurance Claims Specialist

The Claims Specialist is responsible for reviewing, evaluating, and processing claims with a high degree of accuracy and professionalism. This role requires prior claims experience and a strong understanding of medical terminology, documentation, and claim-related medical assessments. The Claims Specialist ensures timely adjudication while upholding quality standards and delivering excellent service to internal and external stakeholders.

Key Responsibilities

• Review and process incoming claims in accordance with company policies, guidelines, and regulatory requirements.
• Accurately enter claimants’ insurance data into claims processing systems.
• Analyze claim information, supporting documents, and medical records to determine accuracy and eligibility.
• Identify discrepancies or missing information and follow up with providers, employers, or claimants as needed.
• Apply medical knowledge to interpret clinical notes, treatment plans, medical terminology, and diagnostic codes.
• Ensure timely adjudication and maintain productivity and quality expectations.
• Document all claim actions clearly and accurately in the system.
• Collaborate with internal teams such as Quality Assurance, Customer Support, and Medical Review units to resolve complex cases.
• Escalate high risk or unusual claims to leadership or medical reviewers as appropriate.
• Respond to internal queries regarding claim statuses and processing issues.
• Follow up on pending or denied claims as needed.
• Support continuous improvement through feedback, trend identification, and recommended process enhancements.