Claims Specialist

Regis Remote Office

About The Position

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.

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.

Nice To Haves

Strong knowledge of medical, dental, vision, disability, and ancillary insurance claims processing

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