Operations Claims Specialist

Responsibilities

• Review claims against contract and policy provisions to ensure accuracy and appropriate resolution
• Process transactions accurately with complete documentation and payment validation
• Identify and document outstanding requirements and required next steps
• Maintain clear and detailed claim notes for continuity of service
• Ensure adherence to regulatory, compliance, and procedural standards
• Respond to customer and internal partner inquiries via phone and email
• Communicate clearly, professionally, and with empathy, especially in sensitive claim situations
• Research and resolve claim-related inquiries within service level expectations
• Escalate complex or high-risk issues appropriately
• Identify and report errors, process gaps, and improvement opportunities
• Support workload balancing and queue management priorities
• Partner with peers, leadership, and cross-functional teams to resolve issues
• Provide mentoring, coaching, and peer training (for Sr. Operations Claims Specialist)
• Conduct quality reviews and identify trends

• Operations Claims Associate: 0–2 years of operations or insurance-related experience
• Operations Claims Specialist: 2–3+ years of claims processing experience with demonstrated proficiency
• Sr. Operations Claims Specialist: 3+ years of advanced claims experience, including complex or contestable claims
• Sr. Operations Claims Analyst: 5+ years of experience with expertise in complex or contestable claims
• Strong analytical, critical thinking, and problem-solving skills
• High attention to detail with ability to manage multiple priorities
• Strong written and verbal communication skills, including handling sensitive situations with empathy
• Ability to work both independently and collaboratively