What does a claims service specialist do?
A claims service specialist works at insurance companies where they are in charge of reviewing and processing insurance claims according to protocols and policies. Among their usual responsibilities include conducting investigations, gathering and verifying documentation, traveling to different areas to examine property damages or personal injuries, conducting interviews, negotiating with external parties, and developing plans to optimize operations. Moreover, a claims service specialist must keep abreast with the latest changes in laws regarding insurance claims and policies.
Claims service specialist responsibilities
Here are examples of responsibilities from real claims service specialist resumes:
- Manage expedition of appeals via problem solving and collaboration with other departments.
- Perform data entry and assessment evaluations regarding admitting patients in facilities.
- Verify demographics, review EOB's, bill charges and modifiers.
- Answer all correspondence pertaining patient, provider or policy per HIPAA guidelines.
- Review payment invoices to verify correct CPT codes are used before making payments.
- Respond to adverse benefit determination decisions on the appropriate DOL and HIPAA compliant format.
- Work with insurance companies for coverage verification to ensure correct member waiver status and compliance with HIPPA regulations.
- Assist on operation duties such as balancing ATM, assisting in opening and closing procedures, and ensure safety of team.
- Assist the member with filing necessary claims for any ATM issue, fraud or dispute claims for unauthorize transactions to account.
- Follow established government guidelines relating to HIPPA.
- Monitor for arbitration decisions and provide expedient responses appropriately.
- Negotiate/Settle cases in mediation, arbitration, or litigation.
- Coordinate payment arrangements for personal injury and cash patients on delinquent accounts.
- Correspond with physicians and patient account representatives to review explanation of benefits, medical records, and medical appeals.
- Used CPT-4 and ICD-9 coding.
Claims service specialist skills and personality traits
We calculated that 12% of Claims Service Specialists are proficient in Customer Service, Process Claims, and Data Entry. They’re also known for soft skills such as Computer skills, Customer-service skills, and Interpersonal skills.
We break down the percentage of Claims Service Specialists that have these skills listed on their resume here:
- Customer Service, 12%
Support team supervisor with overseeing reporting Customer Service Representatives, acting in supervisory role in supervisor's absence.
- Process Claims, 9%
Process claims for new groups after plan has been built; testing benefits for accuracy and efficiency.
- Data Entry, 7%
Specialized in policy claims assignments Answer high-volume phone calls while inputting recorded data entry Answering questions regarding policy, procedures remaining professional
- Auto Claims, 6%
Perform clerical and administrative duties related to auto claims
- Telephone Calls, 5%
Received, screened, and routed high volume of incoming telephone calls and other electronic correspondence.
- Strong Analytical, 5%
Demonstrate strong analytical skills, and the ability to produce great claim work
Most claims service specialists use their skills in "customer service," "process claims," and "data entry" to do their jobs. You can find more detail on essential claims service specialist responsibilities here:
Customer-service skills. Another essential skill to perform claims service specialist duties is customer-service skills. Claims service specialists responsibilities require that "representatives help companies retain customers by professionally answering questions and helping to resolve complaints." Claims service specialists also use customer-service skills in their role according to a real resume snippet: "answer an average of 40 calls per day by establishing insurance claims and addressing customer inquiries and solving problems. "
Interpersonal skills. claims service specialists are also known for interpersonal skills, which are critical to their duties. You can see how this skill relates to claims service specialist responsibilities, because "representatives should be able to create positive interactions with customers." A claims service specialist resume example shows how interpersonal skills is used in the workplace: "applied strong interpersonal and communication skills, as well as product knowledge to establish a selling relationship with customers. "
Patience. claims service specialist responsibilities often require "patience." The duties that rely on this skill are shown by the fact that "representatives should be patient and polite, especially when interacting with dissatisfied customers." This resume example shows what claims service specialists do with patience on a typical day: "handled over 30 customer problems daily with patience. "
Problem-solving skills. Another crucial skill for a claims service specialist to carry out their responsibilities is "problem-solving skills." A big part of what claims service specialists relies on this skill, since "representatives must determine solutions to customers’ problems." How this skill relates to claims service specialist duties can be seen in an example from a claims service specialist resume snippet: "leveraged propriety resources and computer applications to file new claims and bring existing claims to resolution. "
Listening skills. Lastly, "listening skills" is an important element of what a claims service specialist does. Claims service specialist responsibilities require this skill because "representatives must listen carefully to ensure that they understand customers in order to assist them." This resume example highlights how claims service specialist duties rely on this skill: "manage state funded disability insurance claims; communicated with patients, private insurance companies and employer. "
The three companies that hire the most claims service specialists are:
- GEICO60 claims service specialists jobs
- Chubb8 claims service specialists jobs
- Arbella Insurance4 claims service specialists jobs
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Compare different claims service specialists
Claims service specialist vs. Service agent
A service agent is an individual whose primary function is to provide a friendly service to internal and external customers about the organization's products and services. An agent should be people-oriented, highly motivated with a positive and friendly attitude. Although an agent usually works in a call center, an agent can communicate in various ways, such as the telephone or often face to face. The minimum educational requirement of being a service agent is a high school diploma; however, the customer service experience is a plus.
There are some key differences in the responsibilities of each position. For example, claims service specialist responsibilities require skills like "process claims," "data entry," "auto claims," and "strong analytical." Meanwhile a typical service agent has skills in areas such as "regular maintenance," "credit card," "quality standards," and "pet." This difference in skills reveals the differences in what each career does.
Service agents really shine in the technology industry with an average salary of $30,711. Comparatively, claims service specialists tend to make the most money in the insurance industry with an average salary of $40,059.service agents tend to reach similar levels of education than claims service specialists. In fact, service agents are 0.3% less likely to graduate with a Master's Degree and 0.0% more likely to have a Doctoral Degree.Claims service specialist vs. Special service associate
A service associate's role is to assist customers either through phone or in person. One of the service associate's primary responsibilities is to attain customer satisfaction by answering queries, performing troubleshooting methods, assisting in navigating through difficult tasks, handling complaints, resolving issues, and even processing payments. Furthermore, a service associate needs to be equipped with good communication skills to build rapport with clients as there are instances where they have to sell products and services.
In addition to the difference in salary, there are some other key differences worth noting. For example, claims service specialist responsibilities are more likely to require skills like "process claims," "data entry," "auto claims," and "telephone calls." Meanwhile, a special service associate has duties that require skills in areas such as "front end," "customer orders," "customer satisfaction," and "customer transactions." These differences highlight just how different the day-to-day in each role looks.
In general, special service associates achieve similar levels of education than claims service specialists. They're 1.5% more likely to obtain a Master's Degree while being 0.0% more likely to earn a Doctoral Degree.Claims service specialist vs. Service associate
Specialists are employees who are responsible for specific tasks or activities in the department they are assigned to. The actions or tasks they work on are related to their educational background or work experiences. They are usually highly skilled in specializations related to the work they are assigned to. Specialists are also highly trained on the competencies that are required of their specialty. As such, they are focused on the skills and competencies that are needed to enhance their experience in their specific field further.
The required skills of the two careers differ considerably. For example, claims service specialists are more likely to have skills like "process claims," "auto claims," "strong analytical," and "insurance claims." But a service associate is more likely to have skills like "sales floor," "patients," "quality customer service," and "basic math."
Most service associates achieve a similar degree level compared to claims service specialists. For example, they're 3.1% more likely to graduate with a Master's Degree, and 0.5% more likely to earn a Doctoral Degree.Claims service specialist vs. Specialist
Even though a few skill sets overlap between claims service specialists and specialists, there are some differences that are important to note. For one, a claims service specialist might have more use for skills like "process claims," "data entry," "auto claims," and "strong analytical." Meanwhile, some responsibilities of specialists require skills like "patients," "work ethic," "patient care," and "exceptional client. "
The average resume of specialists showed that they earn similar levels of education compared to claims service specialists. So much so that theyacirc;euro;trade;re 4.9% more likely to earn a Master's Degree and more likely to earn a Doctoral Degree by 0.7%.Types of claims service specialist
Updated January 8, 2025
