Claims Processor (Non-motor)

Job Summary

A Claims Processor is responsible for the accurate and timely processing of claims submitted by clients, policyholders, or claimants. This role involves reviewing claims, verifying documentation, ensuring adherence to company policies, and ensuring that claims are processed efficiently and in compliance with regulations.

Key Responsibilities

• Claims Review & Assessment: Handle more complex or high-priority claims, ensuring all documentation is complete, accurate, and in compliance with relevant policies and regulations. Verify supporting documentation, such as medical records, receipts, or proof of loss.
• Claims Processing: Process claims within established timelines, ensuring the appropriate action is taken for claim approval, rejection, or escalation.
• Claims Settlement: Assist in determining settlements or payouts in accordance with company guidelines, policies, and procedures, ensuring fairness and accuracy.
• Escalation Management: Handle escalated claims or issues that cannot be resolved by junior staff, ensuring timely and effective solutions. Act as a subject matter expert for the team.
• Problem Resolution: Identify and resolve minor issues or discrepancies in claims processing. Flag more complex cases to senior staff or managers for further investigation and resolution.
• Quality Assurance: Review and ensure the accuracy of claims data entered by junior staff, making recommendations for corrections and improvements as needed.
• Follow-up: Follow up with clients, healthcare providers, third-party vendors, or internal teams to obtain missing documentation or information required to complete claims.
• Compliance & Adherence: Ensure that all claims are processed according to company policies, industry regulations, and legal requirements. Stay updated on relevant laws and regulations related to claims processing. Assist with audits and ensure the department follows proper procedures.
• Claims Coordination: Work closely with Claims Adjusters, Managers, and other departments (e.g., legal, underwriting) to ensure smooth claims processing and resolution. Coordinate actions needed for claims, ensuring timelines are adhered to and proper handling of claims, and address any issues that arise.
• Team Leadership & Mentorship: Provide guidance, training, and mentorship to junior Claims Assistants, helping to develop their skills and ensure consistency in claims handling. Assist with onboarding new team members.
• Claims Reporting: Generate and review regular reports on the status of claims, identifying trends, bottlenecks, or issues requiring attention. Report any irregularities or discrepancies in claims data to the Claims Supervisor or Manager. Identify any systemic issues or areas for process improvement.
• Administrative Support: Provide general administrative support, including preparing claim-related documentation, reports, and scheduling meetings when necessary.
• Process Improvement: Identify inefficiencies or recurring issues within the claims process and suggest or implement improvements to streamline workflows and enhance team performance.
• Claims Data Management: Maintain accurate records of claims in the system, tracking claim progress and ensuring timely resolution. Generate and review reports for managers to assess claims performance or trends.

Required Qualifications

• Education: Associate’s or Bachelor’s degree in a related field is a plus.
• Experience: At least 3–4 years of experience in claims processing or a related field, with a strong understanding of claims management and procedures.
• Skills:
• Advanced knowledge of claims processing software and Microsoft Office Suite (Excel, Word, etc.).
• Strong organizational and multitasking abilities to manage multiple claims effectively.
• Excellent communication skills, both written and verbal, to communicate with clients, colleagues, and external parties.
• Problem-solving and decision-making skills for handling complex claims and issues.
• Ability to work under pressure and meet deadlines while maintaining high accuracy.
• Leadership skills, with experience mentoring or supervising junior staff.
• Strong attention to detail and accuracy in claims documentation.

Desired Skills

• Strong problem-solving abilities to address issues that may arise during the claims process.
• Ability to work independently and as part of a team.
• Customer service skills, with the ability to address concerns and queries from clients effectively.
• Ability to meet deadlines and manage a high volume of claims.