eFinancial · 1 month ago
(Remote) Senior Claims Examiner
United States
Full-time
Remote
Mid, Senior Level
$71K/yr - $92K/yr
5+ years expeFinancial is looking for a Senior Claims Examiner to work alongside their third-party administrator and Claims Manager. The role involves analyzing, evaluating, and settling life insurance claims while ensuring compliance with departmental and statutory guidelines.
Financial ServicesInsuranceInsurTechLife Insurance
Responsibilities
Communicate effectively and respectfully with customers, attorneys, and co-workers via phone, e-mail, online chat, and in person
Review newly reported claims and log them on the pending claims log
Document each claim file thoroughly in accordance with departmental procedures, including notes on claim review, information obtained, and final decisions
Review and interpret insurance policy provisions to ensure accurate and timely claim decisions
Review any adverse decisions, and decisions outside authority limit, with the Claims Manager. Consult with the Legal Department as needed
On claims within the Senior Claims Examiner’s authority limit (500,000), confirm benefits and statutory interest are calculated correctly
Respond to inquiries from customers and attorneys regarding claim matters, consulting with the Claim Director and/or Legal Department as needed
Work with Fidelity Life’s Underwriting Department on contestable claim referrals and other complex claims as needed
Handle and log specific State and NAIC policy locator searches
Mentor and support third-party claims administration staff
Monitor trends in claims experience, escalate issues to management, and recommend or implement corrective actions. Keep management abreast of any trends in claims experience, unfavorable or otherwise
Work on special projects and other duties as assigned by the Claims Manager
Perform quarterly claim audits focusing on third-party claim handling
Assist FLA Sarbanes-Oxley audit team, internal audit team, external reinsurance representatives and external state regulators with claim audits or market conduct exams
Handle Department of Insurance claim complaints or requests in a timely and professional manner
Stay current on all laws, regulations, and industry updates that impact claim handling and compliance
Support FLA actuarial or Finance teams in reserve setting, claims trend analyses or other requests
Participate in continuous improvement initiatives and suggest proactive changes to operations based on data-driven insights
Help track and analyze claim durations, denial rates, appeal outcomes, and financial impact
Support M&A activity, if applicable
Qualification
Required
5+ years of life claims experience, with proven proficiency in adjudicating contestable and/or accidental death benefit claims (preferred)
Demonstrate knowledge of medical terminology, regulatory compliance including but not limited to unfair claims practices, and privacy requirements
Ability to meet deadlines while performing multiple functions
Proficient in MS Office applications and the Internet
Ability to proactively analyze and resolve problems
Attention to detail
Flexibility and willingness to adapt to changing responsibilities
Excellent written communication, interpersonal and verbal skills
Ability to perform basic mathematical calculations including addition, subtraction, multiplication, division and percentages
Proactive and outside-the-box thinker
Independent and organized work style
Ability to maintain strong performance while working remotely and independently, if applicable
Strong judgment and discretion when handling highly confidential business, employee, and customer information
Team player and creative, critical thinker highly desired
Preferred
Completion of LOMA courses and/or courses offered by the ICA Claims Education program is preferred but not required
Legal or Paralegal Certifications optional but useful
Benefits
Medical Insurance: Choose from a variety of plans to fit your healthcare needs.
Dental Insurance: Coverage for preventive, basic, and major dental services.
Employer-Paid Vision: Comprehensive eye care coverage at no cost to you.
Employer-Paid Basic Life and AD&D Insurance: Peace of mind and additional protection.
Employer-Paid Short-Term and Long-Term Disability Insurance: Financial support in case of illness or injury.
401(k) Plan: Save for your future with a company match to help you grow your retirement savings.
PTO and Sick Time accrue each pay period: Take time off when you need it
Annual Bonus Program: Performance-based bonus to reward your hard work.
Company
eFinancial
Efinancial is an insurance agency that offers life insurance services. It is a sub-organization of Vericity.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Marty Schroeder
Chief Revenue Officer (CRO)
Melissa Balsan
EVP and Chief Marketing Officer
Recent News
Investment Executive
2024-02-10
2023-12-23
Investment Executive
2023-12-23
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