What does a claim specialist do?
A claims specialist is responsible for processing insurance claims, reviewing insurance coverage, and analyzing claims cases. Claims specialists' duties include negotiating claims settlements, validating claims to prevent fraud, creating court testimonies as needed, developing claim review plans, and checking necessary documents and related resolve claims. A claims specialist must have strong analytical and critical-thinking skills to authorize claim payment and investigate complex and unusual claims. Claims specialists should also have extensive knowledge of the insurance processes to handle various cases, following legal policies and regulatory procedures.
Claim specialist responsibilities
Here are examples of responsibilities from real claim specialist resumes:
- Assist in the streamlining of EDI process to manage workflow of EDI claims.
- Manage claims on desk, route/queues, and ECHS within specify turn-around-time parameters.
- Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
- Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
- Upgrade CPT-4 and ICD-9 coding procedures, staying in step with many manage care plans changing reimbursement schedules.
- Manage expedition of appeals via problem solving and collaboration with other departments.
- Provide administrative assistance taking dictation, handling telephone calls, set up meetings.
- Train on both ACAS and HMO platforms.
- Coordinate with insurance companies on insurance claims; and resolve millions of dollars in balances - Sr.
- Handle and dispose of claims in litigation by preparing and developing strategy with defense counsel and consensus relative to litigation handling.
- Present evaluations and status reports to Sr.
- Verify all member and provider information is correct and also make sure all HCPCS codes are correct
- Process all inpatient and skill nursing claims with correct DRG and CSM codes to paid allowable amount.
- Used windows base system to access client information for loss assessments, post and reassign claims to adjusters.
- Verify post billing edits to ensure correct coding bill unit amounts and CPT codes to ensure clean claim submission.
Claim specialist skills and personality traits
We calculated that 19% of Claim Specialists are proficient in Customer Service, Litigation, and Patients. They’re also known for soft skills such as Analytical skills, Detail oriented, and Math skills.
We break down the percentage of Claim Specialists that have these skills listed on their resume here:
- Customer Service, 19%
Provided exemplary and timely customer service, immediately confirming coverage or effectively identifying and promptly addressing any gaps in coverage.
- Litigation, 7%
Handled and disposed of claims in litigation by preparing and developing strategy with defense counsel and consensus relative to litigation handling.
- Patients, 5%
Completed required claim forms for patients to request reimbursement for services rendered by both developmental pediatrician and psychology staff.
- Claims Handling, 4%
Possessed homeowner & auto policy knowledge and applies appropriately to claims handling to determine coverage if necessary on customer inquiries.
- Quality Standards, 4%
Answered questions within the department and relayed information to the Claims Supervisor regarding individual reports reflecting daily production and quality standards.
- Excellent Organizational, 4%
Detail oriented with excellent organizational skills.
Common skills that a claim specialist uses to do their job include "customer service," "litigation," and "patients." You can find details on the most important claim specialist responsibilities below.
Analytical skills. To carry out their duties, the most important skill for a claim specialist to have is analytical skills. Their role and responsibilities require that "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay." Claim specialists often use analytical skills in their day-to-day job, as shown by this real resume: "solved complex problems involving coverage, liability, risk analysis, investigations, and litigation management. "
Detail oriented. Another essential skill to perform claim specialist duties is detail oriented. Claim specialists responsibilities require that "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." Claim specialists also use detail oriented in their role according to a real resume snippet: "prepared customer correspondence and detailed reports for litigation to ensure the gathering of critical information and adherence to company guidelines. "
Communication skills. A big part of what claim specialists do relies on "communication skills." You can see how essential it is to claim specialist responsibilities because "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts." Here's an example of how this skill is used from a resume that represents typical claim specialist tasks: "command of written and verbal communication skills for contact and/or negotiation and litigation. "
Interpersonal skills. Another crucial skill for a claim specialist to carry out their responsibilities is "interpersonal skills." A big part of what claim specialists relies on this skill, since "adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering." How this skill relates to claim specialist duties can be seen in an example from a claim specialist resume snippet: "contribute to a team environment by maintaining excellent interpersonal skills and demonstrating flexibility with daily operations/functions. "
The three companies that hire the most claim specialists are:
- Zurich149 claim specialists jobs
- Sedgwick LLP119 claim specialists jobs
- Expeditors93 claim specialists jobs
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Compare different claim specialists
Claim specialist vs. Medical claims examiner
A medical claims examiner determines whether an insurer will be covering losses from accidents and illness. They are responsible for evaluating insurance claims and applications, following up with insurance adjusters to protect an insurer from financial loss, ensuring information integrity, and ensuring standard guidelines are adhered to. They are also tasked with approving payment and facilitating additional investigation. Qualifications for this position include knowledge of medical terminology.
There are some key differences in the responsibilities of each position. For example, claim specialist responsibilities require skills like "litigation," "patients," "excellent organizational," and "excellent interpersonal." Meanwhile a typical medical claims examiner has skills in areas such as "medical treatment," "provider contracts," "cpt-4," and "process claims." This difference in skills reveals the differences in what each career does.
Medical claims examiners really shine in the technology industry with an average salary of $52,782. Comparatively, claim specialists tend to make the most money in the insurance industry with an average salary of $56,779.On average, medical claims examiners reach similar levels of education than claim specialists. Medical claims examiners are 2.1% less likely to earn a Master's Degree and 0.8% less likely to graduate with a Doctoral Degree.Claim specialist vs. Senior claims examiner
Senior claims examiners review, assess, and process the insurance claims of their clients. The examiners provide recommendations for claims-related resolution. It is their responsibility to examine and authorize the investigation of insurance claims as conducted by insurance adjusters. They check the claims and the insurance policies to ensure that all the information is right. During the settlement, they are expected to be careful in keeping the records with details of the process.
In addition to the difference in salary, there are some other key differences worth noting. For example, claim specialist responsibilities are more likely to require skills like "patients," "excellent organizational," "excellent interpersonal," and "data entry." Meanwhile, a senior claims examiner has duties that require skills in areas such as "property damage," "tpa," "medical management," and "medical treatment." These differences highlight just how different the day-to-day in each role looks.
Senior claims examiners earn a higher average salary than claim specialists. But senior claims examiners earn the highest pay in the finance industry, with an average salary of $92,671. Additionally, claim specialists earn the highest salaries in the insurance with average pay of $56,779 annually.In general, senior claims examiners achieve similar levels of education than claim specialists. They're 0.1% less likely to obtain a Master's Degree while being 0.8% more likely to earn a Doctoral Degree.Claim specialist vs. Senior claims representative
A senior claims representative serves as a client's primary point of contact when processing insurance claims. Their responsibilities include meeting with clients to identify their needs, gathering and verifying documentation, conducting investigations to determine the validity of insurance claims, liaising with external parties, and negotiating the amount of compensation. Furthermore, as a senior claims representative, it is essential to lead and serve as a mentor to junior claims representatives, all while implementing the company's policies and regulations, including its vision and mission.
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a claim specialist is likely to be skilled in "patients," "quality standards," "excellent organizational," and "medical terminology," while a typical senior claims representative is skilled in "automobile claims," "claims process," "coverage analysis," and "sr."
Senior claims representatives typically earn similar educational levels compared to claim specialists. Specifically, they're 0.7% less likely to graduate with a Master's Degree, and 0.0% less likely to earn a Doctoral Degree.Claim specialist vs. Senior claims adjuster
A senior claims adjuster is in charge of inspecting and analyzing insurance claims to validate and adjust payments. Among their responsibilities include reviewing and verifying claims documents, visiting sites to investigate property damages and personal injuries, gathering evidence such as photos and videos, and conducting interviews with witnesses and clients. Moreover, as a senior claims adjuster, it is essential to lead and serve as a mentor to fellow claims adjusters while enforcing and promoting the company's policies and regulations.
Types of claim specialist
Updated January 8, 2025
