Claims Operations Specialist: Carrier & Data Excellence

Davies; Santa Ana (CA); On-site; USD 34,000 - 44,000; Full time

Benefits offered by this job

Medical, dental, and vision plans

401(k) with employer matching

Paid holidays

Discretionary Time Off (DTO)

Job summary

Davies North America is seeking an Operations Specialist in Santa Ana, CA to support client-facing claims processes and act as a liaison among carriers, underwriters, and claim handlers. The role emphasizes timely, accurate information exchange and adherence to program requirements.

The position focuses on carrier communications, data management, and reporting to maintain data quality and program efficiency while coordinating with internal teams to meet deadlines and regulatory expectations.

Qualifications

• 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.

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 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 – essentially act as a file closer.

Skills

Claims processing

Client communication

Data entry

Microsoft Office

Documentation

Tools

Claims management software

Carrier portals

MS Office

Data management

Job description

Davies North America is seeking an Operations Specialist in Santa Ana, CA to support client-facing claims processes and act as a liaison among carriers, underwriters, and claim handlers. The role emphasizes timely, accurate information exchange and adherence to program requirements.

The position focuses on carrier communications, data management, and reporting to maintain data quality and program efficiency while coordinating with internal teams to meet deadlines and regulatory expectations.