Description
The Operations Specialist is a client-facing role responsible for claims support, serving as a key liaison among the carrier, underwriting teams, claim handlers, and management.
Key Responsibilities
Carrier & Client Communications
- Serve as a primary operational point of contact for carrier representatives, underwriters, and other program stakeholders.
- Coordinate with the carrier’s underwriting teams to obtain risk codes, policy information, classifications, bordereau data, and other information required for accurate claim reporting.
- Communicate with the carrier as claims are received and follow up promptly when information or documentation is incomplete.
- Facilitate timely communication among the carrier, management, and claim handlers regarding program requirements, data needs, and operational issues.
Claims Data Management
- Review newly received claims and ensure required claim information is obtained and accurately entered into the claims management system.
- Retrieve policies, claim documents, and related materials from the carrier’s portal or other designated systems.
- Organize, upload, and maintain documents within the claims management system in a clear and consistent manner.
- Monitor claim data for accuracy and completeness and follow up on missing or inconsistent information.
Program Administration
- Maintain and update program guidelines, workflows, reference materials, and operating procedures.
- Work with the carrier and claim handlers to ensure carrier requirements and procedural updates are clearly communicated and consistently implemented.
- Identify operational issues, coordinate with appropriate stakeholders, and assist in developing practical solutions.
- Support the implementation of new reporting requirements, process changes, and program enhancements.
Reporting & Quality Assurance
- Maintain and support key performance indicator (KPI), bordereau, and other carrier reporting requirements.
- Monitor performance against applicable reporting standards, service expectations, and program requirements.
- Identify deficiencies, trends, or recurring issues and communicate them to management in a timely manner.
- Assist management in implementing training, updated procedures, or corrective actions when necessary.
Operational Support
- Provide day-to-day operational assistance to claim handlers and management.
- Assist with special projects, audits, file reviews, data validation, and program-related initiatives.
- Support workflow management and process improvement efforts designed to enhance service delivery, data quality, and claim handler efficiency.
- Perform other duties and provide additional support as needed to meet program and business requirements.
Team Support
- Provide Medicare Compliance support including checking eligibility and meeting reporting deadlines.
- Check payee names in the OFAC system to clear for check issuance.
- Maintain a small pending of settled claims and report to carriers.
Skills, Knowledge & Expertise
Required:
- Experience in insurance, claims administration, underwriting support, program operations, or a related field.
- Working knowledge of insurance terminology, policy information, and claims processes.
- Excellent organizational skills, with the ability to manage multiple priorities and meet deadlines in a high-volume environment.
- Strong verbal and written communication skills, including the ability to communicate professionally with clients, underwriters, claim handlers, and management.
- High level of attention to detail and commitment to data accuracy and complete documentation.
- Proficiency with claims management systems, Microsoft Office applications, carrier portals, and related business tools.
Preferred:
- Experience working with delegated authority, third-party administrator (TPA), managing general agent (MGA), or carrier program business.
- Familiarity with bordereau reporting, KPI monitoring, and insurance data management.
- Experience working directly with underwriting and claims teams.
- Experience supporting specialty insurance programs or transportation and environmental claims operations.
Benefits
- Medical, dental, and vision plans
- A 401(k) plan with employer matching
- Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees
- Paid holidays
- Life insurance and short-term and long-term disability coverage