JOB PURPOSE
Plays a critical role in executing high- quality claims operations, providing technical expertise for complex cases, ensuring procedural transparency and regulatory compliance, and working closely with cross- functional teams to deliver a customer- centric claims experience.
KEY ACCOUNTABILITIES
Key Accountabilities (1)
Technical Claims Operations
- Collaborate with the medical review unit to interpret complex health records or lab results that may impact payout decisions.
- Identify exclusions, disputes, or risk indicators within claims files and recommend resolution strategies or escalation actions when appropriate.
- Propose enhancements to forms, evaluation checklists, and expert commentary frameworks to streamline decision- making and improve accuracy.
- Draft professional, transparent customer and agent correspondence for cases requiring clarification, additional verification, or declined outcomes, aligning with company policies.
- Maintain secure records and contribute to internal case libraries by documenting notable technical issues and best practices for team reference and training."
- Work jointly with Legal to assess claims involving beneficiary disputes, fraud risk, or confidentiality restrictions.
- Track operational KPIs such as average turnaround time, supplemental documentation requests, and rejection rates, offering insights to optimize performance and reduce complaints.
- Perform technical assessments of complex claims, including death benefits, critical illness, accident coverage, and waiver- of- premium cases, with thorough review of policy terms and supporting documents.
- Provide technical guidance to junior staff and peers on handling special cases or incorporating updated product or policy criteria.
- Serve as an internal quality reviewer (peer reviewer) for cases flagged for potential fraud, discrepancies, or requiring in- depth evaluation.
- Support data reconciliation efforts between paper documentation and system entries, ensuring consistency for internal audit and reinsurance purposes.
- Validate key documents such as medical records, death certificates, accident reports, and legal statements, ensuring compliance with the benefit conditions.
Key Accountabilities (2)
Internal Collaboration
- Join internal innovation teams focused on streamlining workflows, strengthening document handling, and delivering superior claimant experience.
- Offer ideas to simplify coordination steps across departments, especially in document handover, internal approvals, and customer data verification processes.
- Collaborate effectively with departments such as Underwriting, Product, Customer Service, IT, and Legal to resolve complex cases with consistent and aligned information flow.
- Participate in testing new tools (evaluation systems, claims software), providing feedback based on daily operational experience to improve usability and reliability.
- Actively maintain and grow technical expertise through internal documentation, knowledge- sharing sessions, recurring training, and exposure to process optimization initiatives.
- Support the creation of internal reference documents, including guides for exceptional cases, response templates, and claims evaluation checklists.
- Mentor and assist junior or less- experienced staff in handling specialized claims cases, strengthening overall team capabilities.
- Join recurring technical meetings with management and cross- functional teams to share updates, analyze case examples, and contribute specialist insights to workflow enhancement.
- Help nurture a professional and collaborative working environment that encourages learning, sharing, and personal growth within the Claims team.
- Serve as a subject- matter contact point for non- technical departments (e.g. Sales, Customer Service) when claims- related inquiries arise involving benefit eligibility, resolution mechanics, or legal obligations.
Key Accountabilities (3)
Quality control and process improvement
- Collaborate with claims system developers to recommend UI adjustments, improve record retrieval features, or add approval support tools.
- Participate in internal peer audits across claims teams to harmonize processing standards and ensure consistent quality across functions.
- Analyze common processing errors or discrepancies to identify root causes and recommend corrective actions to minimize recurrence.
- Share real- world claims handling examples in improvement workshops and offer professional perspectives to challenge or refine proposed workflows.
- Recommend updates to technical checklists, instructional templates, and case triage workflows to promote clarity, consistency, and reduce systemic missteps.
- Propose implementation of technologies such as automated alerts for missing documents, dashboard- based risk data analysis, and integration with external verification APIs.
- Monitor customer feedback related to transparency, resolution time, and service response quality, and suggest enhancements to meet evolving service expectations
- Assist management in compiling quality control data, identifying operational trends, and preparing periodic reports for internal reviews or external audits.
- Contribute to the development of product- specific evaluation guides, categorizing claims by benefit type and risk level to promote specialized case handling.
- Conduct periodic reviews of processed claims to ensure procedural compliance, document completeness, and accuracy in applying benefit terms, particularly in complex or sensitive cases.
- Promote a team- wide quality culture through sustained accuracy, peer- to- peer review practices, and constructive feedback loops.
- Support onboarding and internal training programs focused on quality assurance, educating peers on error identification and correct procedural application.
