eFinancial

Senior Claims Examiner

eFinancial

full-time

Posted on:

Location Type: Remote

Location: Remote • Illinois • 🇺🇸 United States

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Salary

💰 $70,720 - $91,520 per year

Job Level

Senior

About the role

  • 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.

Requirements

  • 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.
  • 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.

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard skills
life claims experienceadjudicating contestable claimsadjudicating accidental death benefit claimsmedical terminologyregulatory complianceproblem analysismathematical calculationsclaims trend analysisclaim auditsdata-driven insights
Soft skills
effective communicationattention to detailflexibilitywritten communicationinterpersonal skillsorganizational skillsindependent work styleteam playercritical thinkingproactive problem solving
Certifications
LOMA coursesICA Claims Education programLegal CertificationParalegal Certification