Insurance Claims Specialist

The Claims Specialist is responsible for reviewing, evaluating, and processing claims with a high degree of accuracy and professionalism. This role requires prior claims experience and a strong understanding of medical terminology, documentation, and claim-related medical assessments. The Claims Specialist ensures timely adjudication while upholding quality standards and delivering excellent service to internal and external stakeholders. Key Responsibilities Review and process incoming claims in accordance with company policies, guidelines, and regulatory requirements. Accurately enter claimants’ insurance data into claims processing systems. Analyze claim information, supporting documents, and medical records to determine accuracy and eligibility. Identify discrepancies or missing information and follow up with providers, employers, or claimants as needed. Apply medical knowledge to interpret clinical notes, treatment plans, medical terminology, and diagnostic codes. Ensure timely adjudication and maintain productivity and quality expectations. Document all claim actions clearly and accurately in the system. Collaborate with internal teams such as Quality Assurance, Customer Support, and Medical Review units to resolve complex cases. Escalate high risk or unusual claims to leadership or medical reviewers as appropriate. Respond to internal queries regarding claim statuses and processing issues. Follow up on pending or denied claims as needed. Support continuous improvement through feedback, trend identification, and recommended process enhancements. Minimum of 4 CXC Subjects including English A Minimum of 1+ years of claims processing experience in medical claims entry, billing or a related health care administrative role preferred. Familiarity with medical terminology and comfort reviewing medical records or clinical documentation. Familiarity with U.S healthcare system, insurance terminology and claims processing. Strong analytical and critical-thinking skills with high attention to detail. Excellent written and verbal communication skills. Ability to work independently while meeting deadlines and quality targets. Proficiency in claim systems, Microsoft Office, and general computer software. Strong organizational and time management skills. As your prospective employer, we need to process your Personal Data as needed to evaluate your qualification for the position you are applying for with Sutherland. During the recruitment process, your Personal Data may be transferred outside of Jamaica and disclosed to third parties in the normal course of the recruitment and/or employment process or as needed to comply with applicable laws. This may include transferring information to our affiliated Companies for purposes connected to your employment with the company or to the management of Sutherland’s business.