What does a claims specialist do?

1 Role and responsibilities

A claims specialist's main responsibility is to ensure that claims are addressed quickly, precisely, and justly. Depending on the claim's type and complexity, a claims specialist may be responsible for a variety of tasks including reviewing the claim documents and verifying eligibility and coverage of the claimant, contacting claimants or policyholders for additional information or evidence, researching and analyzing the claim to identify its value, negotiating settlements or payments with claimants or providers, approving or denying the claim based on policy terms and conditions, documenting and updating the claim status and records, communicating with claimants or policyholders about the claim's outcome and resolution, reporting any issues or disputes to supervisors or managers, and adhering to industry legal and ethical standards.

2 Skills and qualifications

To become a claims specialist, you typically need a bachelor's degree in a relevant field such as business, finance, law, or health. However, some employers may accept a high school diploma or an associate's degree with relevant work experience. Additionally, depending on the type and jurisdiction of the claims you handle, you may need to obtain a license or certification from a state or professional organization. For example, if you work with insurance claims, you may need to pass an exam and complete a continuing education program to maintain your license.

Besides the formal education and credentials, successful claims specialists possess analytical and problem-solving skills to evaluate and resolve claims; communication and interpersonal skills to interact with different parties and convey information clearly and professionally; negotiation and persuasion skills to reach fair and satisfactory settlements or payments; attention to detail and accuracy to verify and document claims; organizational and time management skills to handle multiple claims and deadlines; computer and technical skills to use various software and tools to process and track claims; as well as adaptability and flexibility to cope with changing policies, regulations, and situations.

3 Challenges and rewards

Working as a claims specialist can be both challenging and rewarding. Challenges may include dealing with complex, fraudulent, or disputed claims that require more investigation and verification, handling emotional claimants or providers who may not agree with your decision, balancing the interests and expectations of all parties involved, keeping up with the changing policies, regulations, and standards of the industry, and working under pressure to meet deadlines and quotas. Rewards may include helping people who have suffered losses, providing quality service and customer satisfaction, developing expertise in a specific area or type of claims, advancing your career and earning potential by gaining more experience, skills, and credentials, and working in a dynamic environment with different people and cases.

4 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?