Claims Specialist

Claims Specialist Position Summary

The Claims Specialist is responsible for the accurate and timely examination, processing, and resolution of medical and ancillary insurance claims. This role serves as a primary point of contact for claimants, providers, and clients, ensuring high levels of service, compliance, and operational efficiency.

Essential Duties and Responsibilities:

• Examine, process, and calculate medical, dental, vision, gap, and related claims, ensuring accuracy and compliance with policy provisions
• Review claim filings, documentation, and reports for completeness and accuracy
• Process claims reimbursements in a timely manner
• Assist with filing and tracking short-term and long-term disability claims
• Assist with medication issues, prior authorizations, and appeals
• Verify benefits and provide accurate insurance information to providers
• Respond to inbound and outbound calls, emails, and faxes from claimants, providers, and clients
• Respond to inquiries regarding claim status, coverage, and policy interpretation
• Identify and prioritize urgent claims, communicate with team members, and assist in workload coordination to prevent backlog
• Analyze claim issues, gather necessary documentation, and resolve discrepancies
• Escalate complex claims or unresolved matters to the Claims Manager as appropriate
• Maintain confidentiality and ensure compliance with HIPAA and company policies
• Meet productivity, accuracy, and customer service standards
• Provide professional and timely communication to client groups to ensure satisfaction and service standards are met
• Document all client communications accurately in internal systems

Qualifications and Requirements

• Minimum of 1–3 years of experience in claims processing, insurance administration, healthcare billing, or a related field.
• Strong knowledge of medical, dental, vision, disability, and ancillary insurance claims processing preferred.
• Understanding of insurance terminology, policy interpretation, and benefit verification.
• Familiarity with HIPAA regulations and confidentiality standards.
• Bilingual proficiency required: Fluent in English and Spanish (spoken and written).
• Strong analytical and problem-solving skills with high attention to detail and accuracy.
• Excellent verbal and written communication skills.
• Strong customer service orientation with the ability to handle sensitive or complex situations professionally.
• Ability to work independently while collaborating effectively within a team environment .

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted.* Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP *Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.