Senior Claims Specialist

Senior Claims Specialist

Senior Claims Specialist is responsible to adjudicate complex Individual Life and Critical Illness claims. This role is also accountable for Client experience and strong claims management practices which require aligning work practices, performance, and initiatives to reflect the organization’s strategic priorities.

• Adjudicates the most complex claims such as higher profile claims, higher dollar value claims or claims with increased litigation risk.
• Apply medical knowledge to adjudicate claims and use appropriate case management principles and tools for effective claims management.
• Ability to work professionally and effectively with a diverse group of people.
• Strong organizational skills, including the ability to prioritize work and multi-task.
• Strong research, analytical, critical thinking, problem solving skills and decision-making skills.
• Strong computer skills, proficient in PC environment and MS Word, Excel, and email systems.
• Attention to detail with documentation, reporting and communication.
• Ability and desire to work in a fast-paced, service-oriented environment.
• Excellent verbal and written communication skills, with the ability to be both pleasant and professional.
• Ability to initiate and prioritize regular work duties and projects.
• Identifies emerging issues and trends to inform decision-making.
• Develop solutions and make recommendations based on an understanding of the business strategy and stakeholder needs.
• Provides advice and guidance on implementation of solutions.
• Supports the execution of strategic initiatives in collaboration with internal and external stakeholders.
• Builds effective relationships with internal/external stakeholders.
• Participates in a variety of change management activities including readiness assessments, planning, execution, evaluation and sustainment of initiatives.
• Help prepare quality assurance documentation and provide documented feedback.
• Identifies system enhancements for claims management systems to resolve identified negative claims trends or situations and improve overall effectiveness.
• Participates in testing of claims management systems to identify potential adverse impacts of any system change and escalates as required to mitigate the potential impacts.
• Participates in the design, implementation and management of core business/group processes.
• Adjudicates assigned claims for multiple products, including investigating claim details to determine validity, conducting telephone interviews, consulting with medical consultants and legal resources, coordinating independent assessments, analyzing financial information, documenting detailed case management action plans, making eligibility decisions, re-evaluating claims being appealed, communicating decisions verbally and in writing as required, and release payments.
• Follow established policies and procedures including authority and signing authority to manage the risks inherent in claims operations and escalate any issues or concerns.
• Follow appropriate guidelines in addressing client concerns and complaints, including documentation of claims to the Complaint’s Ombudsman.
• Exercises judgment to identify, diagnose, and solve problems within given rules.
• Works independently on a range of complex tasks, which may include unique situations.
• Escalates claim issues to Leadership and Claim Committee and prepares Case Summary.
• Represents during a lawsuit including being a witness at trial, examinations for discovery, participate in mediations and settlement conferences.
• Identifies business needs, designs/develops tools and training programs; may include delivery of training to audiences.
• Contributes to fraud detection and prevention efforts.
• Broader work or accountabilities may be assigned as needed.

• A minimum of 10+ years of experience in Individual Life and Critical Illness claims.
• Expert level knowledge of Individual insurance product, contracts and policy, as well as experience working with reinsurance.
• Experience working with reinsurance and understanding of treaties.
• Deep knowledge and technical proficiency gained through extensive education and business experience and Microsoft Copilot.
• Verbal &…