What Is a Claims Specialist?
Are you thinking of what career path to choose or considering a career change? If you are a good negotiator and have organizational and problem-solving skills, you may be suitable for a claims specialist job. This article will explain what is a claims specialist, and what this job description involves.
What Is a Claims Specialist?
Claim specialists provide administrative and customer relations support for processing insurance claims. They play a crucial role in all phases of the claims process, from the beginning until the final payout.
More precisely, claims specialists gather information, review all documents, and check data if necessary. In case they find issues, these specialists work quickly to resolve them. They serve as liaisons, helping to communicate between the insured party and the insurer, service provider, or other relevant parties.
Role and Responsibilities
Daily responsibilities
If you are looking for jobs for claims specialists, you need to know what to expect in a job advertisement which includes the roles and responsibilities a claims specialist must have. Such responsibilities include:
- Reviewing insurance claims – The claims specialist analyzes submitted insurance claims to check whether the provided information is correct.
- Verifying information and assessing claim validity – Claims specialists verify policy details, coverage, and other important information to check whether the claim aligns with the insurance policy terms.
- Investigating discrepancies and potential fraud – As a claim specialist, you need to investigate any inconsistencies in the claim to prevent fraudulent claims.
- Communicating with clients, policyholders, and other stakeholders – One of your daily activities would be communicating with stakeholders. You will need to answer inquiries, provide updates, etc.
- Processing and settling claims – As a claim specialist, you will have to handle administrative tasks like paperwork, documentation, and payment processing. You will also need to negotiate settlements according to policy terms.
Types of claims handled
- Health insurance claims – This claim type includes claims related to medical expenses, prescriptions, treatments, and hospital stays. Claims specialists check coverage, process bills, and work on timely reimbursement.
- Auto insurance claims – This group includes accidents, vehicle damage, and liability claims. As a specialist, you must analyze the situation, determine fault, and ensure compensation.
- Property insurance claims – This category involves claims due to events like fire, theft, or natural disasters. Claim specialists must assess the damage, estimate costs, and ensure repairs.
Skills and Qualifications
Essential skills
To become a successful professional, first, you need to possess and acquire several claims specialist skills that will help you do your job efficiently. You need to be attentive to details to analyze claims.
Claims specialists should possess analytical and problem-solving skills to analyze and resolve claims. Besides these skills, it is indispensable to possess strong communication abilities. As a claim specialist, you must interact with different people and pass information clearly and professionally.
Finally, having organizational and time management skills is important to handle multiple claims and deadlines.
Educational requirements
To become a claims specialist, you usually need a bachelor’s degree in business, finance, law, or healthcare. Yet, some employers may accept a high school diploma or an associate’s degree with relevant work experience.
Moreover, based on the type and jurisdiction of the claims, you may need a license or certificate from a certain organization. For example, you may need the Certified Claims Professional (CCP) certificate, which shows that you understand the basic principles of managing insurance claims, competency in practical application, and a commitment to this profession.
Another example is if you work with insurance claims, you may need to pass an exam and have a continuing education program to maintain your license.
Experience and training
Prior experience is important because it helps you understand industry practices, such as regulations and customer expectations. Besides, if you have worked with claims before, you will be more accurate and efficient in processing them.
Another advantage is having experience with customer support. That way, you will be more prepared to handle and resolve issues, which leads to better customer satisfaction. But that is not the only factor that leads to better results. On-the-job training is also important. It involves initial training, mentorship, and role-specific training, such as property, auto, or health insurance claims.
Continuous education is vital in maintaining and refreshing knowledge, ensuring it remains current with new developments. This ongoing learning includes diverse opportunities such as certifications, workshops, seminars, and professional development courses.
Common Challenges
As a claim specialist, you may face some important challenges and stressful situations.
- Handling complex and high-stress cases – Claims often involve many details, and you need to understand the policies. As a claim specialist, you will need to go through different scenarios like fraudulent claims or severe accidents, such as vehicle collisions, natural disasters, or workplace injuries, which are high-stress cases.
- Dealing with dissatisfied claimants – It is common to manage frustrated or dissatisfied claimants. Their dissatisfaction usually results from claim denials, delays, or insufficient settlement.
- Keeping up with industry regulations and changes – Insurance is a dynamic industry with frequent regulation and policy updates. As a claim specialist, you must educate yourself on these changes to ensure compliance in claims processing.
Find the Best Claims Specialist Jobs With Afni
What is a claims specialist? A claim specialist deals with insurance claims in different industries, such as health or car insurance. Claim specialists report and process these claims and are included in the administrative processing of the claims. They gather information, review all documents, check data, and resolve issues if needed.
If you comply with the claim specialist requirements and possess the skills, you might enjoy following this career path. If you believe job hunting can be a hard experience, we assure you that with companies like Afni, finding your next job as a claims specialist would be quick, easy, and fun.
Author
Samantha Byard is the Recruitment Marketing Manager for Afni and brings a wealth of knowledge and tips for job seekers. She holds a bachelor's degree in public relations and marketing from Mount Saint Vincent University as well as a masters degree in digital marketing and advertising from Liberty University.
