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)

1. Technical Claims Operations

- 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.

- Validate key documents such as medical records, death certificates, accident reports, and legal statements, ensuring compliance with the benefit conditions.

- Identify exclusions, disputes, or risk indicators within claims files and recommend resolution strategies or escalation actions when appropriate.

- Collaborate with the medical review unit to interpret complex health records or lab results that may impact payout decisions.

- Serve as an internal quality reviewer (peer reviewer) for cases flagged for potential fraud, discrepancies, or requiring in-depth evaluation.

- Provide technical guidance to junior staff and peers on handling special cases or incorporating updated product or policy criteria.

- 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.

- 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.

- Support data reconciliation efforts between paper documentation and system entries, ensuring consistency for internal audit and reinsurance purposes.

- Maintain secure records and contribute to internal case libraries by documenting notable technical issues and best practices for team reference and training."

Key Accountabilities (2)

2. Internal Collaboration

- Collaborate effectively with departments such as Underwriting, Product, Customer Service, IT, and Legal to resolve complex cases with consistent and aligned information flow.

- 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.

- Join recurring technical meetings with management and cross-functional teams to share updates, analyze case examples, and contribute specialist insights to workflow enhancement.

- Support the creation of internal reference documents, including guides for exceptional cases, response templates, and claims evaluation checklists.

- Participate in testing new tools (evaluation systems, claims software), providing feedback based on daily operational experience to improve usability and reliability.

- Offer ideas to simplify coordination steps across departments, especially in document handover, internal approvals, and customer data verification processes.

- Mentor and assist junior or less-experienced staff in handling specialized claims cases, strengthening overall team capabilities.

- Actively maintain and grow technical expertise through internal documentation, knowledge-sharing sessions, recurring training, and exposure to process optimization initiatives.

- Join internal innovation teams focused on streamlining workflows, strengthening document handling, and delivering superior claimant experience.

- Help nurture a professional and collaborative working environment that encourages learning, sharing, and personal growth within the Claims team.

Key Accountabilities (3)

3. Quality control and process improvement

- Conduct periodic reviews of processed claims to ensure procedural compliance, document completeness, and accuracy in applying benefit terms, particularly in complex or sensitive cases.

- Analyze common processing errors or discrepancies to identify root causes and recommend corrective actions to minimize recurrence.

- Recommend updates to technical checklists, instructional templates, and case triage workflows to promote clarity, consistency, and reduce systemic missteps.

- 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.

- Participate in internal peer audits across claims teams to harmonize processing standards and ensure consistent quality across functions.

- 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

- Share real-world claims handling examples in improvement workshops and offer professional perspectives to challenge or refine proposed workflows.

- Collaborate with claims system developers to recommend UI adjustments, improve record retrieval features, or add approval support tools.

- Support onboarding and internal training programs focused on quality assurance, educating peers on error identification and correct procedural application.

- Promote a team-wide quality culture through sustained accuracy, peer-to-peer review practices, and constructive feedback loops.

Qualifications and Work Experience

• Bachelor’s degree in Insurance, Finance, Economics, Business Administration or a related field.

• Minimum of 5 years of experience in claims processing, preferably in life insurance or large financial institutions.

• Strong understanding of claims procedures, life insurance product lines, and relevant legal frameworks.

• Proficient in reviewing and analyzing medical records, insurance policies, and accompanying legal documents.

• Effective internal and customer communication skills, with agile problem-solving and adherence to transparency standards.