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Claims Specialist


Job Summary

To handle a limited case load of large and or complex life claims and serve as a referral resource for both Life Claims Technicians and Examiners, to ensure timely and equitable settlement and delivery of excellent customer service.

Job Accountabilities - Key Accountabilities

• Ensure that claims processes and procedures meet state and federal regulatory requirements and that life claims decisions comply with known case law precedents.
• Conduct analysis into life claims activity and produce operational and analytical reports for management.
• Handle insurance department and consumer complaints.
• Work on cases where litigation is anticipated or outside counsel is directly involved in the resolution of a claims issue.
• Review and approve life, disability, critical illness and accelerated benefit payments up to a specified maximum for technicians, examiners & senior examiners.
• Review life claims involving complex, investigative considerations and assist examiners in managing complex cases.
• Evaluate life claims recommended for denial or where reconsideration of earlier action has been requested.
• Summarize pertinent issues and formulate final recommendation to management.
• Consult with Special Investigations Unit, Medical Director, Underwriting department, and Legal department on medical and legal issues related to life claims.
• Maintain record of legal precedents and changes in regulatory and statutory requirements.
• Communicate with Compliance, Law department and outside counsel on litigated claims.
• Assist in preparing responses to interrogatories, and production of documents.
• Assist in preparation of life claims statistical reports and newsletters for internal and field distribution.
• Conduct operational reviews for compliance and quality.
• Counsel with Life Claims staff on changes to practices and procedures in order to maintain compliance with regulatory and statutory changes, case law changes and best practices.

Additional Job Functions


• Ensure that internal quality control standards are met, operational controls are effective and conform to the Internal Control Framework.

• Directly oversee training in the department.

• Assist the Life Claims Supervisor in assessing the competence and capability of the examiner and technical staff.

Business Accountabilities

• Monitor and take responsibility for resources/cash, within defined procedures.
• Evaluate and assess costs and customer needs effectively to value and resolve cases within life claims authority limits.
• Identify and comply with the main principles relevant to legal and regulatory controls that govern standard work practices.
• Collect data from well-established sources and prepare reports including commentary and analysis trends to facilitate the resolution of life claims.
• Monitor life claims handling protocol/customer service charter in order to identify opportunities for improvement.
• Provide clear feedback to customers' enquiries and monitor specific issue handling and resolution.
• Resolve operational day-to-day problems referred from other functions of the business, ensuring an efficient and high-quality service is extended to all internal clients.

Job Qualifications

• Bachelors Degree and 6 or more years of experience in the Claims area

• High School Diploma or Equivalent and 8 or more years of experience in the Claims area

• 10 or more years of direct line claims management experience

• Strong verbal and communication skills