OverviewHowYoullWork
Work Solution: Hybrid
Relocation Eligibility: No
Responsibilities
Position Responsibilities
- Provide strategic and technical leadership for complex, contestable, appealed, escalated, and litigation-related life insurance claims.
- Serve as the senior claims subject-matter expert, providing guidance on policy interpretation, investigations, beneficiary issues, underwriting and medical evidence, fraud indicators, and regulatory requirements.
- Exercise independent judgment within delegated authority and appropriately escalate matters involving significant legal, regulatory, financial, fraud, or reputational risk.
- Lead technical strategy for appeals, disputes, complaints, litigation, and other elevated claims in partnership with Legal, Compliance, and key enterprise stakeholders.
- Develop examiner technical capabilities through education, coaching, mentoring, case consultation, and consistent application of claims standards.
- Analyze claims trends, appeals, litigation, complaints, and quality results toidentifyemerging risks, development needs, and process improvement opportunities.
- Provide senior leadership with actionable insights and recommendationsregardingclaims trends, technical risk, emerging issues, and strategic opportunities.
- Lead claims transformation and modernization efforts, including workflow redesign, automation, AI-assisted capabilities, digital tools, and adoption of new ways of working.
- Partneracross Underwriting, Actuarial, Legal, Compliance, Risk, Investigations, Technology, and Reinsurance to resolve complex matters and strengthen risk management.
- Oversee reinsurance reporting and technical claims resources while promoting fair,timely,accurate, compliant, and customer-focused claim outcomes.
Position Success Criteria
- Anticipates changes in claims complexity, regulation, customer expectations, technology, and workforce capability and translates them into actionable claims strategies.
- Partners with Claims leadership to shape the future-state operating model, technical capability roadmap, and modernization priorities.
- Identifiesopportunities to simplify, automate, and enhance claims processes while ensuringappropriate humanjudgment and controls for complex or sensitive matters.
- Exercises delegated authority and sound judgment for complex, contestable, appealed, escalated, and other elevated claims.
- Integrates policy provisions, claim facts, underwriting and medical evidence, legal/regulatory requirements, fraud indicators, and reinsurance considerations to resolve complex matters.
- Provides technical direction and recommendations for claim disposition, investigation, litigation, settlement, escalation, and transformation initiatives.
- Establisheshigh standardsfor technical quality, documentation, customer communication, professional conduct, and ethical decision-making.
- Builds organizational claimsexpertiseand bench strength through coaching, mentoring, case consultation, formal education, and continuous learning.
- Usesclaims, quality, appeals, complaints, litigation, and operational data toidentifytrends, evaluate outcomes, and recommend improvements.
- Demonstrates deep life insurance claimsexpertiseand strong critical thinking, investigative judgment, communication, negotiation, and stakeholder management capabilities.
Qualifications
Basic Qualifications
- A bachelor'sdegree in business, insurance, finance, legal studies, risk management, or related field.
- 10+ years of progressive life insurance claims experience with substantial responsibility for complex claim adjudication.
- 5+ years of direct experienceadjudicatingor providing senior technical oversight of contestable life insurance claims.
- 5+ years of leadership experience, includingpeopleleadership, technical leadership, or significant claims operational leadership.
- Demonstrated experience with appeals, complex coverage matters, litigation-related claims, investigations, and regulatory requirements.
- Demonstrated experience educating, mentoring, or developing claims examiners and other claims professionals.
Preferred Qualifications
- An advanced degree, such as JD, MBA, or related graduate degree.
- FLMI, ALHC, ACS, ICA, or comparable insurance/claimsdesignation.
- Experience leading claims transformation, technology modernization, automation, analytics, or AI-enabled claims initiatives.
- Experience with reinsurance claim management and complex vendor relationships.
- Experience developing technical claims curriculum, case-based learning, or examinerproficiencyprograms.
While performing the duties of this job, the employee isfrequentlyrequired to stand, walk, sit, use hands and fingers to handle, or feel, talk, hear, and concentrate. Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus.
This job requires the ability to perform duties contained in the job description for this position, including, but not limited to, the above requirements. Reasonable accommodation will bemadefor otherwise qualified applicants as needed to enable them to fulfill these requirements.
