Senior Expert, Claims Handling

JOB PURPOSE

Plays a pivotal role in evaluating, processing, and providing technical guidance for high-complexity insurance claims. This position is accountable for ensuring accuracy, transparency, and compliance within operational procedures, while contributing to system enhancement and strategic cross-departmental collaboration to elevate process effectiveness and customer experience.

KEY ACCOUNTABILITIES

1. Advanced Claims Operations

- Conduct advanced evaluation of high-complexity claims, including death benefits involving legal review, critical illness cases requiring multi-source medical validation, or disputed accident claims.

- Examine the completeness and logic of all documents: insurance policies, medical records, incident reports, death certificates, and legal paperwork related to beneficiaries and claimed benefits.

- Analyze operational risk points and recommend appropriate resolution strategies, including documentation requests, escalation pathways, or coordination with independent assessors.

- Act as technical lead for claims requiring internal review regarding benefit eligibility, product terms, or regulatory interpretation; provide detailed written assessments and recommendations.

- Handle escalated disputes involving claim payout decisions, benefit mechanics, or beneficiary conflicts with professionalism and attention to detail.

- Contribute expert evaluation to new product development discussions, especially identifying areas of claims risk, potential controversy in benefit interpretation, or operational gaps.

- Work directly with Audit and Reinsurance departments to review processed cases, particularly high-payout claims or those requiring shared liability analysis.

- Utilize specialized claims systems for data entry, assessment, decision-making, and recording of professional comments in line with compliance standards.

- Propose upgrades to operational tools: expert-level checklists, early risk alert systems, customer advisory templates, and intelligent case categorization features.

- Assist senior management in handling claims cases with legal sensitivity, public auditability, or reputational significance by providing objective, structured analysis.

- Train frontline staff in advanced technical aspects, particularly medical record interpretation, document authentication, and identification of fraud or legal risk indicators.

2. Internal Collaboration and Professional Capability Development

- Collaborate closely with strategic departments such as Underwriting, Legal, Product Management, Reinsurance, and Customer Service in handling, reviewing, and approving complex claims cases.

- Serve as the technical lead in resolving interdepartmental issues including benefit interpretation, exclusion application, contested claims, or legal risk concerns.

- Represent the technical function in specialized meetings, sharing in-depth case analysis, workflow updates, and critical feedback on newly proposed claims policies.

- Act as advisor to frontline teams, offering expert guidance on sensitive claims assessments and shaping verification methodologies, especially for death and serious illness cases.

- Contribute to internal training materials: multi-tiered claims workflows, cases involving medical/legal assessors, and guidelines for beneficiary conflict resolution.

- Help develop peer auditing models across specialist groups to standardize evaluation protocols based on benefit type and claim risk level.

- Work with IT or Operations departments to upgrade automation checks, intelligent case categorization, and integrated tools for policyclaimbeneficiary validation.

- Propose workload segmentation models based on technical complexity, risk tiering, and payout value to optimize resource use and raise process quality.

- Join professional capability initiatives focused on defining career pathways, aligning skills with operational standards, and identifying targeted development needs.

- Lead or participate in internal mentoring programs to nurture technical growth and dispute resolution skills

QUALIFICATIONS AND WORK EXPERIENCE

-Bachelor's degree in Insurance, Finance, Economics, Business Administration or a related field.

-Minimum of 8 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.