Claims Specialist

About the role

The Claims Specialist evaluates the handling, processing and payment of medical and life insurance claims to improve efficiency and ensure compliance with corporate and regulatory standards.

Key responsibilities

• Review policyholder benefits, business rules, provider contracts and service fees to determine correct claim handling.
• Verify that claim analysts apply company, industry and regulatory standards during adjudication.
• Analyze and adjudicate complex claims including COB, Medicare, reinsurance and life insurance according to policies and procedures.
• Monitor Medicare compliance, conduct research at CMS and update claims policies and procedures.
• Coordinate with other departments to resolve referrals and provide technical assistance on claim adjudication.
• Perform testing of payment rule changes, fee schedule analyses and BETA testing of new Medicare policies.
• Prepare management reports on process efficiency, audit results and analyst performance.
• Investigate electronic claims transmission issues and support audit closure activities.

Required profile

• Bachelor’s degree (or associate degree/60‑64 college credits) with at least 2‑4 years of experience in insurance claims processing, analytics or statistics.
• Intermediate proficiency in English and Spanish (reading, writing and speaking).
• Familiarity with industry‑standard quality parameters and regulatory requirements.

Required skills

• Microsoft Excel
• Microsoft Word
• Microsoft Access
• Microsoft PowerPoint