Customer Service Claims Specialist

Customer Service Irvine, California


Job Description Summary

This position reports to the Supervisor of Customer Service and has additional interaction with the Claims Supervisors as needed. Incumbent is responsible for working claims introduced through the Customer Service  line. The Claims Specialist is also responsible for assisting with all escalated issues, high-level questions, and general questions regarding claims within the Customer Service department.


  • High school diploma or equivalent and two or more years medical claims experience with two or more years call center customer service experience with a strong comprehension of medical terms, medical claim coding and terminology, preferred. 
  • Excellent verbal and written communication skills (including business correspondence and documentation of accounts) to both internal and external customers. 
  • Working knowledge of Employee Retirement Income Security Act (ERISA) and Third-Party Administration plans.
  • Knowledge of current laws regarding Affordable Care Act, Health Insurance Portability, and Accountability Act (HIPAA), and Medicare.
  • Ability to think analytically and be a problem solver.
  • Knowledge of how a claim is paid using multiple pricing tools.
  • Knowledge of how third-party liens are paid.
  • General knowledge of reinsurance and stop loss requirements.
  • Prior experience in reconciling or analyzing general ledger activity including researching debit and credit postings.
  • Proficient understanding of end-user software programs.

Duties And Responsibilities

Customer Advocate

  • Handle incoming claims to the Customer Service team.
  • Handle incoming Customer Service calls as scheduled.
  • Close open calls after claim, issue, and/or escalation is resolved.
  • Assist with processing the team’s open calls when requested.
  • Develop and maintain professional relationship with customer, co-workers, management, consultants, and vendors.

Claims Processing

  • Process claims and/or adjustments as directed by management.
  • Process claims and/or adjustments that are forwarded by Customer Service Reps working systematically so turnaround time is no greater than 30 days or past the client’s performance guarantee agreement.
  • Process claims and/or adjustments that are forwarded through HCPS systematically as new work, so no turnaround time is greater than 30 days.
  • Document every claim with pertinent details that show where claim was adjusted to and from with the claim numbers and the reason for adjustment.
  • Finish processing pending or denied claims for liens and coordination of benefits when requested  information/correspondence is sent in to us. 
  • Audit claims following company processes and standards.
  • Respond to customer inquiries via written correspondence, when necessary.
  • Review and process disputes as directed by our legal process.
  • Process specialized claims for Mexican panel and serve as a knowledge expert in the process.


  • Assist in the mentoring and training of team members and new hires. Serve as a subject-matter expert for Customer Service.
  • Contribute to the development or refining of work processes in order to improve efficiency and effectiveness.
  • Communicate with the appropriate departments and identifies service issues.


  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
  • All other duties as assigned. 

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.