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Claims Associate Jobs in Puerto Rico (NOW HIRING)

Pharmpix

PR · On-site

Properly enter test claims to verify business rules set up in the system. * Perform quality ... Pharmacy Technician Associate Degree or equivalent professional experience. LICENSURE ...

Elevance Health

PR · Hybrid

Puerto Rico. This role requires associates to be in-office 3 days per week , fostering ... and claims. * May also direct operations of offices in different geographic locations.

Pharmpix

PR · On-site

Properly enter test claims to verify business rules set up in the system. * Perform quality ... Pharmacy Technician Associate Degree or equivalent professional experience. LICENSURE ...

Alivia Health

PR · On-site

$14.25 - $17.50/hr

... to process claims to medical plans in a timely and efficient manner. * Assist new pharmacy ... Associate degree in pharmacy technician. * Pharmacy Technician License. * Valid Registration ...

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Claims Associate information

What does a claims associate do?

A claims associate handles claims for an insurance company. As a claims associate, your job duties may include reviewing a customer’s insurance coverage and interviewing those who have filed a claim. Your job is to ensure that a claim is processed correctly, so the customer receives the financial payout to which they are entitled. In this career, you usually work in an office, but you may need to travel to gather information about the claim. There are positions in every insurance industry so that you may work in anything from auto to life insurance. This position requires excellent research and interpersonal skills, and experience in customer service is a plus. Additional qualifications may include an associate degree.

What does a claims associate do?

A Claims Associate is responsible for reviewing, processing, and managing insurance claims submitted by policyholders. Their duties include verifying information, evaluating the validity of claims, and ensuring all necessary documentation is complete. They often communicate with customers, healthcare providers, or other parties to gather additional information and resolve any issues. Claims Associates play a crucial role in ensuring claims are processed accurately and efficiently according to company policies and regulatory guidelines.

What are the key skills and qualifications needed to thrive as a claims associate?

To thrive as a Claims Associate, you need a solid understanding of insurance policies, attention to detail, and basic analytical skills, usually supported by a high school diploma or equivalent. Familiarity with claims management systems, CRM software, and sometimes industry certifications like AIC (Associate in Claims) are commonly required. Strong communication, problem-solving, and customer service abilities set top performers apart. These skills are essential for accurately processing claims, ensuring compliance, and providing a positive experience for clients and policyholders.

What are some common challenges a claims associate may face, and how can they effectively handle them?

Claims Associates often encounter challenges such as managing a high volume of claims, navigating complex policy details, and communicating with clients who may be experiencing stress or frustration. Effectively handling these situations requires strong organizational skills, attention to detail, and clear, empathetic communication. Many Claims Associates find success by proactively prioritizing tasks, seeking guidance from senior team members when needed, and utilizing available technology to streamline documentation and follow-ups.

What is the difference between Claims Associate vs Claims Examiner?

AspectClaims AssociateClaims Examiner
Required CredentialsHigh school diploma or equivalent; some roles may prefer insurance-related certificationsHigh school diploma; insurance certifications like CPCU or similar beneficial
Work EnvironmentOffice setting, interacting with customers and internal teamsOffice setting, reviewing claims and documentation
Employer & Industry UsageInsurance companies, third-party administratorsInsurance companies, adjusting departments
Common Search & ComparisonClaims Associate vs Claims Examiner

The main difference between a Claims Associate and a Claims Examiner lies in their responsibilities. Claims Associates typically handle initial customer interactions and basic claim processing, while Claims Examiners review and assess claims in detail, often making determinations on claim validity. Both roles require similar credentials and work in comparable environments, but Claims Examiners usually have more specialized knowledge and decision-making authority.

Is being a claims associate hard?

Claims associates handle insurance claims processing, which requires attention to detail, strong communication skills, and knowledge of insurance policies. The job can be challenging due to the need for accuracy, meeting deadlines, and managing complex cases, but it is generally manageable with proper training and experience.

What is a claims associate in claims?

A claims associate is a professional who reviews, processes, and manages insurance claims to determine coverage and settlement amounts. They often work with claim documentation, use claims management software, and ensure compliance with company policies and industry regulations.
More about Claims Associate jobs

What are the most commonly searched types of Claims jobs in Puerto Rico?

The most popular types of Claims jobs in Puerto Rico are:

What are popular job titles related to Claims Associate jobs in Puerto Rico?

For Claims Associate jobs in Puerto Rico, the most frequently searched job titles are:

What job categories do people searching Claims Associate jobs in Puerto Rico look for?

The top searched job categories for Claims Associate jobs in Puerto Rico are:

Claims Associate jobs near you

Benefits Configuration Specialist I

Pharmpix

PR • On-site

Full-time

Re-posted 10 days ago

Job description

POSITION SUMMARY

The Benefit Configuration Specialist I report to the Benefits & Network Supervisor and is responsible for setting up business rules in the adjudication system for all PharmPix clients. The Benefit Configuration Specialist I will test claims and perform quality assurance reviews to ensure desired results.

ESSENTIAL ROLES AND RESPONSIBILITIES

  1. Perform accurate client benefit set up for all business rules for PharmPix clients.
  2. Implement new and maintain existing benefit plans, rates, and networks in the OneArk system, consistent with the direction and intent set forth by the client and PharmPix.
  3. Properly enter test claims to verify business rules set up in the system.
  4. Perform quality assurance reviews on set up performed by other team members to ensure accuracy.
  5. Point of contact for both internal and external customers for system functionality and claim research questions.
  6. Become Subject Matter Expert on OneArk functionality to support the Operational areas and backend clients.
  7. Analyze client system requests and work to accommodate within existing systems before having to recommend system enhancements.
  8. Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action.
  9. Research and respond to claims processing and system configuration inquiries from internal departments and backend clients.
  10. Proactively identify setup issues and escalate to the Benefit Implementation Director or Manager for immediate review and resolution.
  11. Support all Quality Management Program initiatives.
  12. Perform other duties as assigned.


TRAINING & EDUCATION

  • Pharmacy Technician Associate Degree or equivalent professional experience.

LICENSURE / CERTIFICATION

  • Puerto Rico Board of Pharmacy Technician Certification (Preferred).

PROFESSIONAL EXPERIENCE

  • One (1) year experience in a PBM/Health Plan Environment (Preferred) or; Retail Pharmacy or; Proven working experience as a data analyst.

PROFESSIONAL COMPETENCIES

Knowledge:

  • Experience in the health insurance industry or PBM is desired.
  • Knowledge of federal and The Commonwealth of Puerto Rico health care delivery and pharmacy regulations/regulatory agencies is preferred.

Skills:

  • Must be detail-oriented and highly organized.
  • Accurately analyze and interpret common Pharmacy Benefit terminology.
  • Manage multiple priorities and work independently in a fast-paced environment.
  • Proficiency in Microsoft Office.
  • Possess a high degree of initiative, judgment, discretion, and decision-making to achieve organizational objectives.
  • Strong verbal, written and presentation communication skills.


Abilities:

  • Ability to work independently and with minimal supervision, demonstrating initiative and problem-solving skills.
  • Able to effectively interact with internal departments, PharmPix clients and other healthcare professionals.
  • Ability to read and interpret documents, write reports and correspondence.
  • Ability to organize and integrate organizational priorities and deadlines.
  • Ability to work independently or part of a team.
  • Fully bilingual English and Spanish.
  • Strong problem analysis and decision-making skills.


PHYSICAL AND MENTAL DEMANDS

  • The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear, sitting, standing, and walking
  • The position requires that weight be lifted, and force be exerted up to 25 pounds.
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ENVIRONMENTAL AND WORKING CONDITIONS

  • This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Require evening or weekend work.

PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans