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Claims Review Specialist
The Claims Review Specialist plays a critical role in supporting the insurance claims process by reviewing and evaluating claims for accuracy, completeness, and compliance with pre-determined agency policies and regulatory standards. This classification involves verifying claim documentation, investigating discrepancies, and ensuring the timely and efficient resolution of claims.
Class Code:
PCR02P
Job Grade:
SGS03
Special Job Requirements:
Typical Functions:
Assess insurance claims to ensure all required information is accurate and complete. Verify claim documentation against policy terms and conditions. Identify missing or inconsistent information and coordinate with the appropriate personnel to resolve issues. Document findings and actions taken for each claim in an organized manner. Communicate claim outcomes and provide necessary explanations to policyholders or internal personnel. Support fraud detection and prevention efforts by reporting unusual patterns or inconsistencies. Stay informed on agency policies, industry practices, and relevant regulations. Collaborate with senior team members and managers to improve claims processing workflows.
Knowledge, Abilities, and Skills:
Strong analytical and problem-solving skills, attention to detail, good written and verbal communication. Willingness to learn and adapt to new tools, technologies, and processes. Experience with using standard office software (e.g., Microsoft Excel, Word). A proactive and team-oriented approach to work. Familiarity with department related programs.
Minimum Qualifications:
High school diploma or GED. Two years of experience in clerical or administrative functions. Satisfaction of the minimum qualifications, including years of experience and service, does not entitle employees to automatic progression within the job series. Promotion to the next classification level is at the discretion of the department and the Office of Personnel Management, taking into consideration the employee’s demonstrated skills, competencies, performance, workload responsibilities, and organizational needs.
Required Certificates:
N/A OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.
Exempt:
N