Claims Administrative Specialist

The Doctors Company

The Doctors Company is seeking an experienced Claims Administrative Specialist to support our Claims team. This is a hybrid opportunity based in Sherman Oaks, CA or Napa, CA.

The Claims Administrative Specialist is responsible for communication with members and callers to obtain necessary written documentation to create an electronic claim file. You will also provide clerical, administrative, and technical assistance to the assigned claims staff; maintain specific, timely, accurate coding and file updates to support data warehouse searches for claims processing and TDC research projects. This position supports employees, member physicians, agents, brokers, vendors, defense lawyers, administrators, and patients.

• Experience in insurance or healthcare industry preferred
• Excellent oral and written communication skills
• Demonstrates organizational skills and attention to detail
• Strong customer service skills and ability to work on a high performing team
• Proficiency within Microsoft suit of products, including Word, Excel, and Outlook
• Ability to follow departmental procedures with a high degree of accuracy and detail
• Ability to prioritize workload to meet pertinent deadlines and response dates
• Ability to handle confidential personal health information in accordance with company policy and PHI rules & regulations
• Ability to support internal and external stakeholders with diverse backgrounds and personalities

• Maintains a broad-based understanding of the company standards and guidelines
• Articulates the guidelines to both internal and outside customers as necessary
• Seeks to actively meet the expected standards and guidelines in all phases of their work product
• Uses appropriate judgment in applying guidelines to achieve the desired outcome
• Obtains information and necessary facts to create an electronic claim file. Accurate and timely data entry after confirming coverage under the applicable policy. Refers to designated manager for assignment and follows up.
• Serves as first point of contact when members, administrators, agents or brokers contact TDC to report a claim file. Utilize phone software during designated work time. As applicable, transfer to appropriate contact and follow-up to obtain required information.
• Acts as primary contact for member service within their assigned region to provide best imaginable service.
• Generates all necessary letters for file opening, closing and in support of their assigned claim specialist(s).
• Orders death certificates, autopsy reports, statute checks and other public records.
• Obtains from necessary parties, signed authorizations and orders medical records.
• Organizes medical records for the claims file and prepares records for expert review.
• Follows-up on closed files for receipt of dismissal and settlement documents.
• Performs various processing duties, such as updating computerized claims records, sending facsimiles/emails, telephone support, and servicing the insured throughout the life of the claims file.
• Completes State Reports and other forms.
• Receives and follow up on all NPDB coding requests.
• Acts as large account point person for reporting allocated and unallocated claims
• Coordinate meetings and correspondence upon request.
• Processes manual payments as needed.
• Prepares accurate settlement check requests and ensures file has Medicare designation
• Provides processing assistance for requests from other departments.
• Manages unallocated files including of defense counsel and monitoring for timely closure.
• Reviews and approves legal invoices on assigned files.
• Manages allocated files with reserves below $30,000, which do not require field investigation. Varies by regional office.
• Performs other duties as assigned.

$46,436 - $60,947

Compensation varies based on skills, knowledge, and education. We consider factors such as specialized skills, depth of knowledge in the field, and educational background to ensure fair and competitive pay.

• Health, dental, and vision insurance
• Health and dependent care tax-free spending accounts with a company match
• 401(k) and Roth IRA with company match, as well as catch-up plans for both
• Paid vacation,…