The Claims Advisor is responsible for delivering professional and responsive customer service while reviewing and processing claims accurately and efficiently. This role evaluates submitted documentation, policy coverage, and eligibility information to adjudicate, pend, investigate, approve, adjust, or deny claims in accordance with contractual provisions, company guidelines, and regulatory requirements. The Claims Advisor applies strong attention to detail and sound decision-making skills to ensure accurate claim outcomes, identify potentially fraudulent activity for leadership review, and maintain productivity and service standards in a fast-paced environment. This position may process various claim types.
Qualifications:
- High School diploma or equivalent; associates or bachelors degree preferred.
- Minimum 2-4 years of experience in claims processing, insurance, financial services, healthcare administration, customer service, or a related field preferred.
- Strong customer service skills with the ability to communicate professionally and empathetically with members, employers, providers, and vendors.
- Demonstrated attention to detail with the ability to review documentation, interpret policies, and make accurate decisions.
- Ability to analyze information, problem solve, and exercise sound judgment in a fast-paced environment.
- Experience handling confidential information with professionalism and discretion.
- Strong organizational and time management skills with the ability to manage multiple priorities and meet productivity standards.
- Proficient computer skills, including data entry and experience working within multiple systems simultaneously.
- Working knowledge of claims processes, insurance terminology, or policy interpretation preferred.
- Knowledge of fraud awareness, compliance requirements, and regulatory guidelines is a plus.
Primary Job Functions:
- Reviews and adjudicates claims by analyzing submitted documentation, policy coverage, eligibility, provisions, exclusions, and endorsements to determine appropriate claim outcomes, including payment, pend status, requests for additional information, adjustments, or denial of coverage.
- Provides professional and responsive customer service through multiple communication channels, including phone, email, text, and chat, while assisting members, accounts, providers, and vendors with claim-related inquiries and resolution.
- Communicates effectively to obtain and validate claim information, explain claim decisions, and deliver a positive customer experience with empathy and professionalism.
- Applies strong attention to detail and sound judgment to ensure accurate and timely claim processing in accordance with company guidelines, contractual requirements, and regulatory standards.
- Demonstrates the ability to work independently as a self-starter while managing multiple tasks, priorities, and systems simultaneously in a fast-paced production environment.
- Investigates claims of a potentially fraudulent or questionable nature and collaborates with leadership regarding findings and next steps.
- Analyze claim information and processes payments, reimbursements, or claim adjustments accurately and efficiently.
- Maintains accurate claim documentation, records, and related statistics to support internal reporting, legal requests, regulatory reviews, insurance department inquiries and other internal or external audits.
- Maintains working knowledge of applicable state regulations, anti-fraud compliance requirements, claims procedures, product knowledge, production standards, and service expectations.
- Updates and maintains claim tracking systems by entering claim information, verifying coverage, and ensuring documentation is complete and accurate.
- Meets established productivity, quality, and service standards while balancing customer service and claim accuracy expectations.
- Identifies workflow improvement opportunities and communicates operational challenges or process impediments to leadership.
The above cited duties and responsibilities describe the general nature and level of work performed by people assigned to the job. They are not intended to be an exhaustive list of all the duties and responsibilities that an incumbent may be expected or asked to perform.
Skills & Competencies Required:
- Strong customer service skills with the ability to communicate professionally, empathetically, and confidently across phone, email, chat, and text channels.
- Excellent attention to detail and accuracy when reviewing claims, policies, and supporting documentation.
- Strong analytical and critical thinking skills with the ability to make sound and consistent decisions.
- Ability to interpret policy provisions, coverage guidelines, and contractual language.
- Effective verbal and written communication skills.
- Strong multitasking and organizational abilities with the capability to manage competing priorities in a fast-paced environment.
- Self-starter with the ability to work independently and manage workload with minimal supervision.
- Problem-solving mindset with the ability to identify issues and recommend solutions.
- Ability to maintain professionalism and composure when handling sensitive or escalated situations.
- Proficient computer skills with the ability to navigate multiple systems and applications simultaneously.
- Ability to meet productivity, quality, and service level expectations consistently.
- Strong collaboration skills and willingness to support team and operational goals.
- Knowledge of claims processing, fraud awareness, compliance requirements, and regulatory standards preferred.
Additional Information:
Full benefit package including medical, dental, life, vision, company paid short/long term disability, 401(k), tuition assistance and more.
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