Manage end-to-end assessment and processing of Life & Health insurance claims within a regional service environment. This role ensures accurate, timely, and compliant claims decisions in line with delegated authority limits, service standards, and established procedures.
Key Responsibilities
Claims Processing & Decision Making
- Assess and process Life & Health insurance claims within delegated authority and service standards
- Ensure compliance with policy terms, claims guidelines, and standard operating procedures
- Perform accurate benefit calculations, verify payee details, maintain adequate reserves, and ensure timely claim settlement
- Monitor and review pending claims to ensure prompt closure
- Identify unusual claim patterns or practices and recommend improvements to strengthen controls
- Resolve processing issues and escalate complex cases when necessary
Stakeholder & Customer Engagement
- Liaise with medical professionals, policyholders, claimants, and agents to gather required documentation and clarify information
- Provide timely updates and insights to internal stakeholders
Service Excellence
- Deliver clear, empathetic, and professional communication to all stakeholders
- Ensure a smooth, transparent, and customer-focused claims experience
Process Standardization & Improvement
- Support standardization of claims processes across markets
- Identify opportunities to improve efficiency, simplify workflows, and enhance straight-through processing
Governance, Risk & Compliance
- Adhere to internal policies and regulatory requirements
- Maintain strong operational controls to mitigate financial, processing, and compliance risks
- Identify risk areas and implement corrective actions proactively
- Support audits, quality assurance activities, and compliance reviews
- Maintain proper documentation and audit trails for all claims decisions
Requirements
- Bachelor's degree or professional certification in Insurance, Healthcare, or a related discipline
- 35 years of experience in Life and/or Health insurance claims processing
- Strong knowledge of medical terminology, medical practices, and coding systems.
- Solid understanding of insurance policy terms and claims assessment principles
- Strong analytical and decision-making skills with the ability to interpret complex information
- High attention to detail and ability to manage high volumes with accuracy
- Excellent interpersonal and communication skills with a customer-focused mindset
- Experience supporting multiple markets is an advantage
- A collaborative team player with a proactive attitude and willingness to learn
