Operations Specialist

Key Responsibilities

• 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.

• 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.

• 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.

• 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.

• 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.

• 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 – essentially act as a file closer.

Skills, knowledge & expertise

• 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.

• 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.

Equal Employment Opportunity & Legal Notices

• Medical, dental, and vision plans to support your health and that of your family
• 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

• Maintain regular and dependable attendance.
• Be available and able to perform job responsibilities during established work hours.