Our client, a well-established insurance provider, is seeking an experienced Health Claims Specialist to join their growing team. In this role, you will independently manage a diverse portfolio of health insurance claims—ranging from standard to moderately complex—ensuring accurate, fair, and prompt resolutions. You will serve as a key technical resource by interpreting medical data, mentoring junior associates, and optimizing workflows to deliver an exceptional customer experience.
Key Responsibilities: Oversee end-to-end processing for health claims; assess coverage, liability, and settlement values within authorized limits. Analyze medical reports, treatment plans, and diagnostic codes to verify coverage validity against policy terms. Support junior team members with policy interpretations, medical terminology, and difficult client interactions to streamline operations. Spot potential fraud indicators, maintain audit-ready digital records, and ensure strict adherence to regulatory standards.
Liaise with policyholders, medical professionals, and brokers to resolve queries efficiently and maintain strong relationships. Verify and process claim payouts, track financial data, and use claims software to improve operational efficiency.