Claims Examiner

The Claims Examiner will independently adjudicates complex and higher-risk life and health claims that require advanced contractual analysis, including contestable claims, accidental deaths, accelerated death benefits, rescissions, and claims involving potential fraud, litigation, or competing interests. Provides technical guidance to Claims Representatives, recommends claim dispositions within delegated authority, and presents matters requiring approval to management.

• Independently evaluate and resolve complex, contestable, and higher-risk claims within delegated authority; prepare well-supported recommendations for matters requiring management approval.
• Communicate with claimants, beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners regarding complex claim requirements, status, and resolution.
• Determine and request the documentation, evidence, and investigations needed to adjudicate complex claims.
• Apply policy provisions, applicable law, underwriting evidence, medical information, and administrative records to determine liability and the appropriate settlement.
• Manage pending complex claims within contractual, regulatory, and departmental timeframes, identifying barriers and escalating material risks.
• Document analyses, decisions, and recommendations clearly in the claim file and present cases requiring approval to management.
• Direct and monitor claim investigations performed by third-party vendors; evaluate findings for relevance, completeness, and credibility.
• Analyze medical records, autopsy and toxicology reports, investigative findings, underwriting evidence, and other records to determine liability.
• Manage contestability and rescission reviews, including coordination with underwriting, legal, compliance, and other business partners.
• Support litigation and regulatory matters, including depositions, examinations under oath, and case preparation, as needed.
• Organize complex claim files for legal review and provide concise case summaries, timelines, and supporting documentation.
• Manage reinsurance activity for assigned complex claims, including timely notice, billing, follow-up on recoverables, and system updates.
• Maintain advanced knowledge of claims law, regulations, tax requirements, and industry practices; apply changes to claim decisions and procedures.
• Apply underwriting principles and evidence when evaluating contestability, material misrepresentation, and rescission issues.
• Identify and assess fraud indicators, determine when enhanced investigation is warranted, and escalate suspected fraud in accordance with company procedures.
• Prepare and analyze reporting related to claim settlements, reinsurance recoveries, financial reconciliations, trends, and assigned management initiatives.
• Serve as a technical resource to Claims Representatives by answering case questions, sharing specialized knowledge, and assisting with training or quality improvement.
• Lead or support special projects, process improvements, and other complex assignments from management.

EducationBachelor’s degree or equivalent combination of education and relevant experience preferred.Advanced insurance education or credentials, such as ALMI, ACS, or comparable coursework, preferred.ALHC or comparable claims-focused credential preferred.Advanced knowledge of life insurance contracts, complex and contestable claims, investigations, and claims procedures required.

Experience/KnowledgeMinimum of three years of progressively responsible life claims experience, including complex claim adjudication.Five or more years of general life insurance experience preferred.

SkillsDemonstrated proficiency in complex claims, including contestable, accidental death, accelerated death benefit, waiver, foreign death, rescission, and fraud-related matters.Advanced organization and prioritization skills with the ability to manage a complex caseload and competing deadlines.Excellent written and verbal communication skills, including the ability to explain complex decisions clearly and professionally.Sound independent judgment and decision-making within delegated authority.Advanced problem-solving, analytical, investigative, and negotiation skills.Advanced product knowledge and ability to interpret contract provisions, underwriting evidence, medical records, and applicable requirements.Demonstrated diplomacy and customer focus when working with beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners.High attention to detail and consistent, well-supported claim documentation.Strong analytical and technical skills, including the ability to synthesize information from multiple sources.Ability to collaborate cross-functionally and provide technical guidance or training to less-experienced claims staff.Proficiency in Microsoft Word and Excel and in claims administration and research systems.

What’s in it for you?

The expected hiring compensation range for this position is $80,800 - $110,000 annually.  This is a remote opportunity working EST.

The total compensation package for this position may include other elements, such as a sign-on bonus, long term incentives, and annual bonuses.  This role is eligible to participate in the Annual Incentive Plan. The current target payment for the position is 8% of base salary, modified for corporate and individual performance. Bonuses are pro-rated based on start date.  This role has 15 vacation days and 10 sick days that are accrued on a bi-weekly basis. Employees also have 9 paid holidays throughout the calendar year.

We have a competitive compensation and benefits package focused on your overall wellbeing.  Employee benefits include health, life, and dental insurance; 401K with company match up to 6% as well as a pension package; generous time off; and wellbeing initiatives throughout the year (we like doing fun stuff).  We’re big on professional development and we’ll support and mentor you in your career progression and expect you to help us pay it forward by helping us develop tomorrow's leaders and growth-focused professionals. We value our teams and our communities and believe in giving back. Enjoy time off to volunteer for those causes that matter most to you!

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors. The Company reserves the right to change benefits plans at any time.