Claims Customer Service Representative II

Insurance Administrative Solutions•Clearwater, FL

About The Position

Review, process, and investigate claims and phone or written inquiries, making informed decisions to resolve them accurately. Apply contract benefits according to established claims processing protocols and report claims-system issues to the appropriate team. Collect, organize, and use information about benefits, contract coverage, and policy determinations. Maintain professional relationships with policyholders, service providers, agents, attorneys, other insurance carriers, coworkers, management, and support staff.

Requirements

High school diploma or GED equivalent.
2–4 years of experience in a fast-paced call center or relevant experience.
Strong verbal and written communication skills.
Ability to clearly explain complex information in a customer-friendly manner.
Proficiency with claims systems and Microsoft Office applications.
Exceptional attention to detail and strong problem-solving abilities.

Nice To Haves

Experience in medical insurance, especially Medicare Supplement plans.

Responsibilities

Interpret contract benefits and explain them professionally to policyholders, agents, and providers.
Provide clear, timely claim status updates to policyholders and providers.
Prepare, send, and follow up on refund request letters as needed.
Create and deliver customer correspondence as needed.
Answer incoming calls and make outbound calls to provide or obtain information in a helpful, professional, and timely manner.
Document calls as they occur and update policy files or imaging systems to maintain an audit trail.
Transfer calls to the appropriate departments to address customer needs efficiently.
Participate in cross-training and group training to improve team efficiency and uphold service standards.
Communicate with supervisors, team leads, and colleagues to support accurate responses and prevent duplicated efforts.
Report claims-processing system issues to the appropriate team.
Perform other duties as assigned to support team needs.