Position Summary
The Employee Benefits Claims Specialist serves as the advocate and point of contact for client employees and HR contacts on claims issues. The role researches, escalates, and resolves problems with carriers (medical, dental, vision, life, disability, voluntary), ensuring timely and accurate resolution and a strong client experience. Key Responsibilities - Serve as the primary contact for client employees and HR administrators with claims questions, denials, and billing discrepancies.
- Open, track, and document claims inquiries and escalations with carriers until resolution.
- Research claim denials, explain benefit coverage and plan provisions, and assist with appeals.
- Coordinate with carrier representatives, account managers, and clients to resolve complex issues.
- Assist with life, STD, and LTD claims by helping employees and employers complete forms and meet deadlines.
- Maintain a claims log and report on open issues, trends, and turnaround times.
- Identify recurring carrier or plan issues and flag them to account teams for renewal and service discussions.
- Maintain confidentiality of protected health information (PHI) in compliance with HIPAA and agency policy.
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