WHAT DOES A CLAIMS SPECIALIST DO?
The Claims Specialist manages daily operations, analyzing client portfolios to enhance claim outcomes and ensuring accurate data for business reporting. This position's responsibilities include supporting strategic client portfolio management, conducting aligned audits, and implementing effective claim management practices. Additionally, this role involves tendering for new business, promoting claims expertise in the market, and ensuring compliance with Medicare and Medicaid pricing standards.
A Review of Professional Skills and Functions for Claims Specialist
1. Claims Specialist Duties
- Claims Settlement: Assessing, coordinating, and settling all claims within own settlement authority.
- Global Claims Management: Responsible for servicing claims for the partner's global insurance book and managing claims for customers across the globe.
- Claims Escalation: Escalating to the Claims Team Lead via the procedures established.
- Claims Improvement Communication: Identifying and communicating any issues or opportunities for improvement with the Claims Team Lead.
- Process Implementation: Implementing new processes to achieve individual and team’s KPIs.
- SLA Compliance: Completing tasks within agreed SLAs.
- Online Claims Management: Managing claims predominantly online (collection of information).
- Translation Assistance: Assisting with content translations.
- Professional Claims Processing: Processing Professional and Hospital claims accurately and timely within the claiming system.
- Guideline-Based Claims Processing: Processing claims according to set guidelines for payment or denial.
2. Claims Specialist Details
- Customer Service & Communication: Provide exceptional customer service and communication to clients.
- Claim Setup: Set up claims by verifying the correct policy, entering all name records, and setting diaries.
- Claim Analysis: Analyze and review insurance claims for accuracy and completeness, obtaining information as necessary.
- Call Management: Answer and direct calls to appropriate team members.
- Payment Handling: Record payments and/or request payments.
- Customer Inquiry Response: Answer general customer inquiries on claim procedures following specific guidelines.
- Documentation Management: Ensure proper documentation of all claim-related communication.
- Claim Facilitation: Facilitate the claim reporting process between Lockton clients and insurance carriers.
- Claim Reporting: Report claim information accurately and promptly to the appropriate insurance carrier on behalf of the client.
- Collaboration & File Management: Collaborate with Account Managers and other team members to manage claim files and achieve accurate and timely claim reporting.
- Mail Distribution: Distribute mail to the proper department.
3. Claims Specialist Responsibilities
- Review Skills: Review reconciliation logs to identify shortage variances.
- Documentation Skills: Prepare documents to present to armored vendors claims against losses in reporting.
- Analytical Skills: Review responses from armored vendors and identify whether the response resolves the claim.
- Reconciliation Knowledge: Gain knowledge of reconciliation to accurately determine if armored responses are valid.
- Research Skills: Research various reports and in applications to verify validity of responses from armored vendors.
- Data Management Skills: Create a workbook to track claim letters, responses, and accurate resolution of each claim.
- Communication Skills: Work closely with the reconciliation team and armored vendors by email and phone to quickly resolve variances.
- Reporting Skills: Prepare various reports for Management such as claims tracker and supporting documents.
- Resource Management Skills: Use available resources to manage workload.
- Team Participation Skills: Actively participate in staff meetings.
- Supervisor Communication Skills: Communicate with supervisors on workload/issues/backlog.
4. Claims Specialist Job Summary
- Claims Preparation: Prepare and submit hospital claims including adjustment and voiding.
- Denials Review: Review denials, coding issues, and audits.
- Claims Follow-Up: Follow up on rejected or denied claims, improper payments, and coding issues.
- Revenue Optimization: Identify issues and patterns with claims/insurance companies to increase revenue and prevent unnecessary denials.
- Regulations Interpretation: Interpret billing, coding, and payment regulations, third-party contracts.
- Training Assistance: Assist the supervisor in training and make recommendations to improve policies and procedures for the unit and the office.
- Data Analysis: Complete variance and trend analyses via spreadsheets, databases, and dashboards.
- COB Investigation: Investigate and accurately update Coordination of Benefits (COB), including refund request letters, reports, mail, etc.
- Policy Adherence: Follow procedures, guidelines, and policies.
- Customer Support: Provide customer support for a 1-800 line inquiries.
5. Claims Specialist Accountabilities
- Operations Management: Manage the day-to-day operations to carry out his/her responsibilities effectively.
- Claims Analysis: Analyze clients' portfolio to understand the details and trend of claims in order to add value to the outcome within a reasonable timeline.
- Data Accuracy: Ensure required claims data and reports are accurate and complete for business reporting purposes (KPIs, etc.).
- Strategy Support: Support the Claims Manager in developing client portfolio management strategy, planning and carrying out Claims Audits/Reviews to ensure alignment to business goals and priorities.
- Client Relationship Management: Work closely with team members in managing client relationships, providing solutions and value-added claims services, including training, claims management, seminars, meetings, etc.
- Claims Management: Assess and manage claims implementing effectiveness management strategies with clients within the terms and conditions of the policy and pricing assumptions.
- Audit Oversight: Ensure aligned client audits are conducted within internal audit framework, and oversee implementation of any remedial actions to improve claims standards.
- Business Development Support: Support the BU in tendering for new business, innovative product development, and in promoting claims profile and expertise in the Japan market.
- Documentation Compliance: Ensure treaty documentation contains agreed terms and conditions, and the relevant claims clauses and articles fulfill acceptable SR standards.
- Claims Pricing: Prices claims according to Medicare, Medicaid, and custom fee schedules.
- Performance Goals: Meets personal and team goals and metrics.
- Data Entry: Manually enters data from CMS1500 and UB04 claims into claiming system.