What does a Claims Service Specialist do?
Claims service specialists assist customers in filing insurance claims, frequently serving as the initial and main point of contact with the customer. They answer questions, review policies and other documents, and provide guidance to ensure claims are submitted in the proper manner to help ensure prompt and efficient processing. They may also serve as a liaison to coordinate communications with adjusters, attorneys, and other insurance agents.
Claims service specialists typically have at least a high school diploma, although a college degree or completion of a technical/business training program is an advantage. Many insurance companies have training programs where they provide instruction for specialists with limited experience. These positions require meticulous attention to detail and excellent customer service skills, as well as strong verbal and written communication skills.
- Escalate claims issues/concerns to senior team members and/or management.
- Maintain claim files and document claim file activities in accordance with established procedures.
- Execute edits within charge review to achieve account resolution.
- Generate reports to monitor the type of errors and their frequency.
- Resolve all correction requests accurately and in a timely approach.
- Review and analyze all information and submit request for payment of claims within company guidelines to supervisor.
- Consult with Supervisor on more complex coverage and technical matters.
- Maintain current knowledge of local industry repair procedures and local market pricing.
- Review content in development to ensure functional specifications defined are executed.
- Assist or prepare files for lawsuit, trial, or subrogation.
- Carry out duties in compliance with all state and federal regulations and guidelines.
- Adhere to high standards of professional conduct consistent with the delivery of superior service.
- Initiate and conduct follow-ups via proficient use of claims systems and related business systems.
- Investigate losses, identify coverage, evaluate liability and damages, review and analyze documents and legal pleadings.
- Open, close and adjust reserves according to company practices designed to ensure reserve adequacy.
- Bachelor's Degree in business.
- Strong problem solving, time management, and critical thinking skills.
- Proficient with Microsoft Office Suite.
- Advanced understanding of HIPAA regulations and privacy protocols.
- Requires careful attention to detail.
- Basic understanding of writing protocol
How much does a Claims Service Specialist make near United States?
Base Pay
Additional Pay
$49,196
/ yrClaims Service Specialist Career Path
Learn how to become a Claims Service Specialist, what skills and education you need to succeed, and what level of pay to expect at each step on your career path.
Years of Experience Distribution
Claims Service Specialist Insights
Suncorp Group“Stressful workload which is not reflective of industry pay Workload is unattainable”
Metrix Insurance“If you're energetic about forging a career in insurance then you could do really well for yourself at Metrix.”
Bexar County“Consistent work and a reliable paycheck.”
Infinx Healthcare“Nope nothing to say if u do work from home employee oriented”
ReqRoute, Inc.“the pay is not the best”
Advanced Call Center Technologies“Good job to work at”
Holston Medical Group“Good people to work with”
Davies Group“Great people to work with”
Frequently asked questions about the roles and responsibilities of a Claims Service Specialist
- Claims Analyst
- Claims Adjuster
- Claims Examiner
- Claims Manager
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How much of a pay cut would you entertain to stay WFH, or work at an office 15 minutes away from your house? I moved companies during COVID, was told verbally my position would be remote, now starting to get pressure to go in the office and have a feeling it’s going to be mandatory multiple days a week, it’s a 50 minute commute. My prior company wants me back, is local and I really enjoyed working there. I don’t know how much they’d offer but I know they can’t match my bonus.