Job Role Description

Insurance > Claims Resolution Specialist

Salary National Average

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Short Description:

A Claims Resolution Specialist is responsible for reviewing, investigating, and resolving insurance or healthcare claims to ensure accurate and timely reimbursement. They analyze claim documentation, identify discrepancies or errors, and communicate with providers, patients, or internal teams to clarify information and facilitate resolution. The role involves maintaining detailed records, ensuring compliance with regulatory and company policies, and supporting reporting or audit processes. Claims Resolution Specialists help optimize the claims process and improve customer or provider satisfaction. Strong analytical, problem-solving, and communication skills are essential for success in this role.

Duties / Responsibilities:

  • Review, investigate, and resolve insurance or financial claims to ensure accurate and timely processing
  • Analyze claim documentation, policies, and contracts to determine coverage, liability, and eligibility
  • Communicate with claimants, internal departments, and third-party vendors to gather necessary information and resolve disputes
  • Identify errors, inconsistencies, or potential fraud in claims and take appropriate corrective action
  • Document claim decisions, communications, and actions in claims management systems for auditing and reporting purposes
  • Collaborate with legal, compliance, and underwriting teams to ensure claims adhere to regulatory and company standards
  • Monitor claim status and follow up on pending issues to ensure timely resolution
  • Provide guidance and support to clients regarding claim procedures, coverage, and documentation requirements
  • Participate in process improvement initiatives to enhance claims handling efficiency and accuracy
  • Prepare reports on claims trends, resolutions, and outstanding issues for management review

Skills / Requirements / Qualifications

  • Education: High school diploma required; associate’s or bachelor’s degree in finance, insurance, business administration, or a related field preferred
  • Experience: 2–4 years of experience in claims processing, insurance, or customer service in a claims environment
  • Analytical Skills: Ability to assess complex information, identify discrepancies, and make informed decisions
  • Technical Skills: Proficiency with claims management systems, MS Office Suite, and related software
  • Communication: Strong verbal and written communication skills for interacting with clients, vendors, and internal teams
  • Problem-Solving: Ability to resolve disputes, identify root causes, and implement corrective actions
  • Attention to Detail: Accuracy in reviewing claim documentation, entering data, and maintaining records
  • Regulatory Knowledge: Familiarity with insurance regulations, policies, and industry standards relevant to claims handling

Job Zones

  • Title: Job Zone Three: Medium Preparation Needed.
  • Education: Most occupations in this zone require vocational school training, on-the-job experience, or an associate's degree.
  • Related Experience: Previous work-related skill, knowledge, or experience is required for these occupations. 
  • Job Training: Employees in these occupations usually need one or two years of on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
  • Job Zone Examples: These occupations usually involve communication and organizational skills to coordinate, supervise, manage, or train others to accomplish goals. 
  • Specific Vocational Preparation in years: 1-2 years preparation (6.0 to < 7.0)

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