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Claims benefit specialist skills for your resume and career

Updated January 8, 2025
3 min read
Below we've compiled a list of the most critical claims benefit specialist skills. We ranked the top skills for claims benefit specialists based on the percentage of resumes they appeared on. For example, 10.5% of claims benefit specialist resumes contained customer inquiries as a skill. Continue reading to find out what skills a claims benefit specialist needs to be successful in the workplace.

15 claims benefit specialist skills for your resume and career

1. Customer Inquiries

Here's how claims benefit specialists use customer inquiries:
  • Maintain quality customer service by following customer service practices; responding to customer inquiries and addressing any patient concerns.
  • Drafted letters; investigated customer inquiries and researched problems.

2. Appeals

Here's how claims benefit specialists use appeals:
  • Determine which appeals needs medical clinical review from Case Management/Nurse.
  • Selected by upper management for special handling issues such as provider and member complaints and appeals.

3. Medical Terminology

Here's how claims benefit specialists use medical terminology:
  • Utilized broad knowledge of medical terminology and benefit plan policies to perform rework calculations.
  • Entered claims while reviewing prior authorization, coding (diagnosis/procedure) and medical terminology.

4. Routine Claims

Here's how claims benefit specialists use routine claims:
  • Analyzed and processed routine claims that could not be auto adjudicated according to Medicare, Provider and Plan Sponsor Guidelines.
  • Analyze and approve routine claims that cannot be auto adjudicated.

5. CPT

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Here's how claims benefit specialists use cpt:
  • Established a working knowledge of CPT, ICD-9, HCPCS codes, terminology, member benefits and claim flow.
  • Processed medical claims following HIPAA guidelines to ensure that the CPT codes and ICD-9 codes were valid.

6. Processing Issues

Here's how claims benefit specialists use processing issues:
  • Prepared and delivered weekly consistency meetings to cover various claim processing issues.
  • Communicated with various internal departments to resolve complex claim processing issues.

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7. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how claims benefit specialists use data entry:
  • Utilized multiple systems to obtain/record claim information and data entry.
  • Maintained a good working knowledge of the operation of data entry devices, applications, job formats, and system commands.

8. Outbound Calls

An outbound call is made by the call center representative to the customers on behalf of the company. Such calls help increase sales and generate revenue for the organization.

Here's how claims benefit specialists use outbound calls:
  • Make outbound calls to Pharmacies, Doctors, Nurses, Members and other health related entities to research information.
  • Do rework and do outbound calls to members and physician offices for updating information.

9. Claim Adjudication Process

Here's how claims benefit specialists use claim adjudication process:
  • Identified discrepancies, and applied all cost containment measures to assist in the claim adjudication process.

10. Medicaid

Here's how claims benefit specialists use medicaid:
  • Subject matter expert for Connecticut Medicaid plan and handled all Connecticut corporate audits.
  • Experience processing Stateside, Medicaid and Medicare medical/hospital claims.

11. Medicare Advantage

Here's how claims benefit specialists use medicare advantage:
  • Process medical claims for a Medicare Advantage program.

12. Medical Insurance Claims

Here's how claims benefit specialists use medical insurance claims:
  • Reviewed medical insurance claims for accuracy and compliance.
  • Processed medical insurance claims for provider payment.

13. ACAS

Here's how claims benefit specialists use acas:
  • Trained on both ACAS and HMO platforms.
  • Utilize Aetna's ACAS system and multiple systems to obtain and record claim information and to help make claim payment decisions.

14. Production Standards

Here's how claims benefit specialists use production standards:
  • Achieved individual production standards and strong adherence to quality cost management.
  • Meet department accuracy and production standards.

15. Processing Service

Here's how claims benefit specialists use processing service:
  • Utilized all applicable system functions available to ensure accurate and timely claim processing service.
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List of claims benefit specialist skills to add to your resume

The most important skills for a claims benefit specialist resume and required skills for a claims benefit specialist to have include:

  • Customer Inquiries
  • Appeals
  • Medical Terminology
  • Routine Claims
  • CPT
  • Processing Issues
  • Data Entry
  • Outbound Calls
  • Claim Adjudication Process
  • Medicaid
  • Medicare Advantage
  • Medical Insurance Claims
  • ACAS
  • Production Standards
  • Processing Service
  • Facilitate Training
  • DRG
  • HCPCS
  • HMO
  • Inbound Calls
  • CMS
  • Electronic Correspondence
  • Cost Containment Measures
  • ICD-9
  • COB
  • Medical Necessity Review
  • Claims Processing Guidelines
  • Quality Standards
  • PPO
  • Insurance Benefits
  • Paper Claims
  • Claims Handling
  • Hospital Claims
  • HIPAA
  • Health Insurance Claims
  • Dental Claims
  • EOB
  • Procedure Codes
  • HCFA
  • Telephone Inquiries
  • Electronic Claims
  • Provider Contracts
  • Claims Issues
  • Plan Sponsors
  • Echs

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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