Role of Los Angeles Anthem Insurance Claims Specialists

Insurance companies hire employees in order to function and protect their bottom line. Although you will never meet them and possibly never even hear their voice, an insurance claims specialist plays a large role in whether your health insurance claim is accepted and paid.

Since health insurance companies like Anthem are in business for a profit, they sometimes make part of the role of a Los Angeles Anthem insurance claims specialist to find reasons to deny claims. If you believe your claim was unfairly denied by such a specialist, a seasoned insurance attorney could help.

The Job of a Claims Specialist

When a claimant or their medical provider submits a claim to the insurance company, the first person to look at the claim is often a claims specialist. The main job of an insurance claims specialist is to review claims that are submitted in order to determine whether they are covered under the insured’s own health care policy. As a part of this job, they will look to see whether proper policies and procedures were adhered to for filing the claim and will determine how much Anthem needs to pay on a claim.

They can approve or deny claims per Anthem company policy. A Los Angeles Anthem insurance claims specialist’s role also sometimes includes collaborating with insurance claims adjustors when a complex claim is filed. When that happens, a claims investigator can also help a claims specialist to further review cases that warrant additional attention.

Other Important Duties

Depending on the office where the claims specialists works and their background they may also be called to:

  • Research the going rate for specific health care procedures, doctor visits, prescriptions, and immunizations
  • Authorize payments on a claim
  • Ensure timely delivery of payments to clients and medical providers
  • Flag claims that may be eligible for third-party recovery
  • Work with other professionals such as lawyers, physicians, and other Anthem employees on claims that require more research or attention
  • Investigate insurance claims or assist with coordinating an investigation

Qualifications To Be an Anthem Specialist

As per the United States Bureau of Labor Statistics, educational, training, and licensing/certification vary by state and individual employer. For some claims specialists, this can mean little or no training in the insurance or medical fields. In California specifically, there are no specific educational requirements, some positions do not even require a college degree or any experience.

When it comes to the physical and mental as well as financial well-being of insureds, it can come as a surprise that claims can be decided by very inexperienced employees. However, even when a state or employer does not require specialized training or education, claims specialists are still bound by the California Health and Safety Code when accepting or denying claims, which adds some protection to claimants.

An Attorney Can Explain the Role of Los Angeles Anthem Insurance Claims Specialists

Not knowing the laws or lacking proper training is not a valid excuse for an unfair denial of a claim or breaking California laws. You deserve to have your claim examined by a professional who knows what they are doing. If the role of Los Angeles Anthem insurance claims specialists seems to be impeding the acceptance of your claim, an experienced insurance attorney can help. Call today to learn more about your options following a claim denial.