Claims Specialist II

About the role

The Claims Specialist II provides responsive, customer-focused support by handling claim requests and ensuring issues are resolved accurately and efficiently. They are responsible for delivering clear updates, answering questions, and working with internal and external partners to provide a smooth, professional experience for customers throughout the claims process.

Responsibilities

• Processes and resolves moderately complex claim servicing requests, including check reissues, payment corrections, reversals/reservices, Refund of Premiums, Waiver of Premiums, and other claim-related items in accordance with policy provisions and established procedures.
• Reviews claim details, payment history, system records, and supporting documentation to identify issues and determine appropriate resolution.
• Researches and analyzes complex claim servicing items, including payment discrepancies, overpayments, and account adjustments ensuring accurate and timely completion.
• Collaborates with internal departments, vendors, providers, insureds, and other appropriate parties to obtain information and resolve outstanding claim issues.
• Conveys simple to moderately complex information (coverage, decisions, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations.
• Handles outbound claim related callbacks, addressing questions, providing status updates, and ensuring timely follow-up and resolution.
• Ensures claims handling is conducted in compliance with applicable statues, regulations and other legal requirements, and that all applicable company procedures and policies are followed.
• Identifies opportunities for process improvements and escalates complex or unusual issues to leadership for review and resolution.
• Performs other duties as assigned.

Qualifications

• A High School Diploma
• An Associate degree or higher in business, insurance, healthcare administration, or a related field preferred; or equivalent years of experience.
• 3+ years of experience in insurance claims, long-term care insurance, life insurance, health insurance, financial services, or a related field preferred.
• Demonstrated experience handling complex claim transactions, payment processing, adjustments, escalations, or customer inquiries.
• Experience interpreting policy provisions, researching claim information, and applying procedures and guidelines to resolve claim issues.
• Possesses demonstrated technical knowledge and skills, including product and industry knowledge, reflective of successful progression through various job family levels.
• Performs work under general supervision.