Claims Specialist Job Description

Claims Specialist Job Description, Skills and Salary

Are you searching for a claims specialist job description? Get to know about the duties, responsibilities, qualifications, and skills requirements of a claims specialist. Feel free to use our claims specialist job description template to produce your own claims specialist job description. We also provide you with information about the salary you can earn as a claims specialist.


Who is a Claims Specialist?

The thought of the choice of a career is a usual thought every growing child has. Sometimes you find out that your choice of career as a child happens not to be the career you chose after all. As you grow up, you begin to have experience of various careers either directly or indirectly, and so begin to develop an interest in specific careers, or sometimes end up being confused as to which career suits you best. You can also choose a particular career and in the long run; you find out that its requirements do not fit you, even after obtaining a degree in it. The best way to go about it is to identify your passion, and what you love doing and then research careers surrounding that passion.

If you have a great desire to solve complex issues claims by providing adequate, considerate, and just services to clients. Are you skilled in investigation, communication, and negotiation? If you flourish in an environment where you can solve insurance claims problems, while following a just procedure, managing costs, and ensuring client satisfaction, then you should consider a career as a Claims Specialist.

Who then is a claims specialist, and what do they do? A claims specialist plays a very important role in the medical, home, automobile, and business insurance industry. He is an individual assigned the task of managing an insurance claims process, taking care of different cases while following lawful policies and dogmatic processes. Their duties also include processing these insurance claims, examining insurance coverage, and evaluating insurance claims cases. Claims specialists also communicate and negotiate with clients, authenticate claims to avoid scams, develop relevant court testimonies, check necessary documents and, resolve claims. You must have, therefore, excellent critical thinking and analytical skills, to enable their authorization of claims payment, and investigate complicated and strange claims.

Furthermore, claims specialists work directly with clients and insurance adjusters and will give reports to the Underwriting manager of claims working in the reward and challenge section of the insurance. Their major duty is replying adequately to clients’ claims and providing call support to them. As a claims specialist, your employer counts on you to provide and promote excellent customer service, both on calls and in-person when handling claims, and also as a relationship contact between the organization and the customer. In some cases, some claims specialists work in offices with occasional travel.


Claims Specialist Job Description

What is a claims specialist job description? A claims specialist job description is simply a list of duties and responsibilities of a claims specialist in an organization. Below are the claims specialist job description examples you can use to develop your resume or write a claims specialist job description for your employee. Employers can also use it to sieve out job seekers when choosing candidates for interviews.

There is so much work attached to a claims specialist, but it would not be a burden to an expert or professional because of the years of experience gained. As an expert, you will find pleasure in rendering these services to the organization and to clients. The major part of your work will be carried out from an office, there would also be a need for occasional short travels in order to make inspections, organize field visits, and carry out research and interviews. You would then need to be a good critical thinker and have the high analytical skill and is expected to have a deep knowledge of the latest regulations and policies in the insurance industry. The job description of a claims specialist is as follows:

  • Examine and scrutinize complex insurance claims to help avoid fraud.
  • Carry out deep site inspections and assessment
  • Provide clear court testimony when necessary.
  • Process and evaluate claims and court rulings.
  • Sustain the relationship and communication existing between the clients and the insurance department.
  • Present and systemize claim review strategies.
  • Remain updated with insurance policies, and local, state, and federal legal adjustments.
  • Direct and drill several SIU investigative analysts.
  • Uphold good working affairs with internal and external associates and peers to ascertain valuable communication and a very high level of customer service.
  • Make proper use of your computer skills via mainframe systems and the internet. Make a decision on payment or rejection of Medicare UB claims while applying suitable codes as obligatory for deny claims.
  • Validate post-billing edits to ascertain exact coding bill unit amounts and CPT codes to guarantee clear claim submission.
  • Conserve strict discretion to HIPAA guiding principles and regulations.
  • Conduct complete evaluation of inner and outer damage to generate a detailed mend estimate within Xactimate software.
  • Evaluate and assess therapeutic claims involving coordination of benefits, Medi-care, and surgery.
  • Sustain privacy of a patient’s data following HIPAA guidelines.
  • Acquire authorization properly by obtaining all credentials needed by following Medicaid’s policy guiding principles.
  • Evaluate and assess claims based on benefits, eligibility, authorizations, and contractual treaty between the HMO and providers.
  • Embrace elevated standards of experienced conduct, and be persistent with the delivery of exceptional services.
  • Free, tighten and adjust the budget in accordance with company procedures designed to guarantee resource adequacy.
  • Propose Special Reserves when the need arises, in accordance with the Corporate Reserving guidelines.
  • Educate novice employees and also equip teammates with intensity on facility claims.
  • Contribute to the assessment procedures to estimate detriment, reserving functions, case value, and manage claims cost.
  • Guarantee adequate documentation of files of allocated files by agreeing with the company and state demands.
  • Retain and evolve the current perception of allocated insurance lines; legal rulings which may affect the claims function; current policies in the claims function; and policy modifications and alterations. This would probably require attendance at various conferences or education sessions.
  • Inaugurate and complete follow-ups via expertise use of claims systems and relating business systems.
  • Make planned proposals for reducing the regularity and stringency of losses through the use of a workers’ payment record, and other claims statistics reports.
  • Design databases conduct incorporated data analysis and prepare corresponding reports.
  • Contribute definitive guide and advice campus-wide to University officials, supervisors, departments, and staff on the understanding and application of worker’s payment and property & casualty policies, rulings, regulations, and procedures, as well as on cost regulation procedures, design and tool training and exposure schemes to transmit this message to the University community.

These are the responsibilities of a claims specialist; though they are numerous, knowledge of almost all, gives you a ladder to climb towards professionalism, and furthermore, opens more doors to better and bigger work opportunities.



Employers do not accept the applications of all who apply for jobs in their organization because they just want workers to work in their firm and get paid, they employ you based on your qualifications. Even if there are minimal applicants for a particular position, they are not obligated to employ unqualified applicants. This is the reason why you should know the necessary qualifications needed for a particular position, before considering writing an application or even going for the profession.

Your qualifications are your tools, which put you in a better position to acquire a particular job or embrace a particular profession. There are various qualifications relevant for the claims specialist career, and they are as follows:

  • Obtain a GED or a High school diploma, a bachelor’s degree, or its equivalent.
  • A minimal experience of about 2 years in a related position.
  • Should possess very good organizational and analytical skills.
  • Sufficient knowledge of the latest insurance-related guidelines and legislations, at the local, state, and federal levels.
  • Excellent communication skills.
  • Superb interpersonal skills.
  • In-depth understanding of insurance claims negotiation and settlement strategies.
  • Ability to resolve conflicts.
  • Ability to travel to meet clients and attend meetings, seminars, or conferences.


Essential Skills

Claims Specialists play a very significant role in the business, health, and insurance industry or sector. They are responsible for reconciling settlements, processing claims, and examining insurance issues.

Your skills are lubricants for work and as such, assist you to carry out your duty in any given profession. There are so many relevant skills of a claims specialist and they include the following:

  • Powerful speaking skills and the capacity to operate effectively with a broad range of districts in a diverse community.
  • Excellent writing skills.
  • Independent decision-making skills and the use of this skill to make adequate judgments and decisions.
  • Documentation skills.
  • Mediation and dispute resolution skills.
  • Superb analytical and mathematical skills.
  • Attention to detail, or detail-oriented skill.
  • Strong interpersonal skills.
  • Swift customer service skills.
  • Data entry skills.
  • Investigation ability.
  • Great listening skills.

These skills complement each other and each is as important as the other. As a claims specialist, you ought to have a very strong communication skill, which includes speaking and writing; this is so because from time to time you will be involved in communication with clients. Communication is viewed as the capability to express one’s thoughts, ideas, and feelings to people through spoken words, written words, and actions. The same applies to the ability to listen properly and with keen attention to clients.

Customer service involves the rendering of assistance to potential and existing clients in a particular industry. This is a fundamental skill required of a claims specialist as it helps him in hand with his interpersonal skill to relate well with clients. Clients love to be treated the right way and in a friendly manner, hence, having good customer service skills would help you achieve this.

Furthermore, a claims specialist should be capable of solving certain mathematical and analytical issues. This is one of the most important skills required of a claims specialist; as he would have to analyze EOBs (Explanation of Benefits), balance insurance, and perform certain adjustments and credits as required. Nevertheless, he should also be detail-oriented because as a claims specialist you will be involved in the review of documents and deteriorated properties, and the overlooking of minor details can have great financial complications. Other skills should not as well be overlooked, as the acquisition of them all gives you high chances of employment.


How to Become a Claims Specialist

When you are filled with thoughts about taking a career, one of the few things you should consider is the steps necessary to achieve it. Some of them have complex and rigid steps, while others may be simple and flexible. This is to enable you to begin and finish well, and to avoid quitting on the way. It actually takes time to finally become a professional claims specialist, but if you consider being a claims specialist, then here are the simple steps to take to make it happen.

Firstly, you should consider getting educated. You can begin by finishing high school or secondary school and obtaining a high school diploma; but then, high school completion is a necessity. While some employers may accept applicants without post-secondary education, the majority would not. If opportune, you can try going for post-secondary education and obtaining a degree or an associate degree in accounting, business, or related disciplines.

The next thing to consider after gaining an education is to apply for a license. The requirements for the application of this license vary from nation to nation and also from state to state. Simply make research your state’s requirements and immediately apply.

Another pivotal step to take is to acquire all the essential skills necessary for the job. There are so many relevant skills to the position of a claims specialist, such as strong communication skills, analytical skills, investigation skills, problem-solving skills, and so on.

Furthermore, you should gain some experience, as it is also very necessary. By working in an office regarding the position of a claims specialist or customer service representative, you not only gain experience, but you develop your acquired skills, and you can get recommendations in the process too. When you must have gained experience and developed your skills for at least 2 years, you can then prepare your resume and apply for a job.

The steps are summarized below:

  • Get an education and acquire a high school diploma, degree, or associate degree.
  • Apply for a license.
  • Acquire relevant and essential skills.
  • Gain some experience.
  • Prepare your resume.
  • Apply for a job.


Where to Work as a Claims Specialist

The area of work in any given profession plays a big role in people’s career choices. As a claims specialist, you can work in various firms and industry that has to do with properties.

The following are possible workplaces for a claims specialist:

  • Health facilities.
  • Insurance companies.
  • Real Estate Management.
  • Automobile companies.
  • Business strategic companies.


Claims Specialist Salary Scale

Every worker or expert wants to be paid adequately for services rendered, none would appreciate being underpaid. Hence, before considering a career, you should also consider the amount you can possibly earn in that career, or better still, the level you can attain through that career and the salary scale therein.

In the United States, the annual salary for a claims specialist is estimated at $69,544, but with an average of $42,597 annually. In the United Kingdom, the average salary of a claims specialist is £25,101 per year. In China, it is estimated at ¥32,576 to ¥119,256. In Nigeria, the average salary of a claims specialist is ₦870,360 to ₦2,849,520.

Generally, the salary scale of a claims specialist is in the high side, but you can apply for promotion and better positions in the insurance industry.

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