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About Sydney Administrators

Sydney Administrators is a rapidly expanding, privately owned third-party administration firm that supports brokers and carriers in the health and life insurance sectors. Their product portfolio encompasses Accident Indemnity, Accident Medical Expense, Cancer, Critical Illness, Short-Term Disability, Hospital Indemnity, Long-Term Care, Medical Gap, Medicare Supplement, Short-Term Care, Term Life, Universal Life, and Whole Life insurance. The company prides itself on a client-centric approach grounded in the expertise of its carrier and consultant leadership team.

Role Overview

We are seeking a qualified Claim Specialist to join our team and aid in servicing our expanding clientele. This role demands an individual dedicated to delivering excellent service and accurately processing claims in alignment with company and industry standards.

Key Responsibilities

Manage Supplemental Health insurance claims efficiently and accurately, adhering to carrier policies, regulatory regulations, and internal procedures.
Conduct independent examination and analysis of claims to determine insured eligibility, applicable coverages, and allowable costs based on certificate benefits.
Handle claims-related inquiries from both internal teams and external customers via various communication channels, ensuring accuracy and confidentiality.
Provide courteous and professional response to member and provider inquiries over the phone, drafting correspondence when required.
Resolve claims issues, including denials and appeals autonomously, while escalating complex cases appropriately. Maintain professionalism to promptly resolve concerns on initial contact.
Develop a detailed understanding of each client’s products, policies, and customized benefits, ensuring adherence to client-specific plans.
Assist Claims Manager and leadership with client-related business projects and programs as necessary.
Document claim decisions, notes, and communication in the system accurately. For unresolved matters, update information thoroughly and direct them to relevant personnel quickly.
Consistently uphold quality standards within the department while managing a high volume of claims in a dynamic environment.

Required Qualifications

At least five years of experience analyzing claims, specifically in supplemental health insurance (medical claims experience such as Medicare or Medicaid is not acceptable).
Preferred experience includes life, disability, and supplemental health insurance claim analysis.
Familiarity with medical coding systems including CPT, ICD-10, and revenue codes is advantageous.
Bachelor’s degree or equivalent work experience is preferred.
Strong communication skills in writing and speaking with a customer-centric focus and efficient team collaboration.
Excellent analytical capabilities, strong attention to detail, and proficiency in Microsoft Excel, Word, Teams, and Outlook.
Experience with accumulator calculations and adjustments along with strong numerical skills are highly valued.
Highly organized with the ability to multitask effectively in a fast-paced setting.
Proven capacity to perform well independently in a results-driven environment and demonstrate accountability.
Commitment to the highest ethical standards within the insurance industry.
Ability to assess and prioritize the needs of clients and external partners effectively.
Bilingual candidates are strongly preferred but not mandatory.

Additional Information

This is a fully remote position open to applicants residing anywhere in the United States or those who prefer to work from home in the Tampa, Florida region. Sydney Administrators is an equal opportunity employer welcoming qualified candidates aligned with our values and standards.

Claim Specialist