Job Description

The Claims Review Specialist will function as the Licensing Specialist. The Licensing Specialist is an entry-level position responsible for processing applications for licenses, certifications, and permits within a state government agency. The Licensing Specialist ensures that applications meet all requirements, verify information, and prepares documentation for approval. This position is crucial for maintaining the integrity of the licensing process and ensuring compliance with state regulations.

This position requires on-site employment with no remote or hybrid options available.

Job Responsibilities and Expected Results

• Review and analyze insurance licensing applications to ensure they meet all state and federal requirements.
• Process licenses, renewals, and reinstatements.
• Stay current on all state and federal laws, regulations, and bulletins related to insurance and agent licensing.
• Maintain accurate records of all agency data in applicable systems.
• Work collaboratively to achieve common goals.
• Perform additional duties as assigned by supervisory/managerial staff to support the team and organization.

Position Information

Job Series: Program Operations – Claims Review

Classification: Claims Review Specialist

Class Code: PCR02P

Pay Grade: SGS03

Salary Range: $39,171 – $57,973

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.

Primary Responsibilities

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 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.

Licensure/Certifications

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.