Expert, Claims

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.

Key Accountabilities (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 policy–claim–beneficiary 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

Key Accountabilities (3)

• Quality Assurance and Process Innovation
• Conduct in-depth quality reviews of processed claims, particularly large payouts, legally involved cases, or customer-disputed files.
• Analyze potential errors or systemic risks within the claims workflow to propose preventive measures and strengthen operational controls.
• Establish technical evaluation criteria for Specialist and Senior Specialist levels to support periodic performance and quality audits.
• Contribute to the design of internal audit frameworks for Claims, ensuring focus on material risks, transparency, and operational realism.
• Collaborate with IT and system development teams to enhance technical tools such as claims dashboards, fraud behavior detection, and automated high-risk triage.
• Provide technical input during workflow redesign sessions to assess legal compliance, operational feasibility, and policy alignment.
• Guide the integration of APIs with medical authorities, legal systems, or reinsurers to accelerate verification and improve data accuracy.
• Monitor enterprise-wide performance indicators including complaint rates, average resolution time, and first-pass approval ratios to identify bottlenecks and inter-team disparities.
• Recommend multi-variable triage models (complexity, legal sensitivity, product type, geographic region) for restructuring claim handling protocols.
• Participate in customer experience improvement initiatives within the claims process, covering feedback interface, communication style, update mechanisms, and post-resolution sentiment analysis.
• Act as primary liaison with external auditors and reinsurers during claims case reviews; prepare professional justification, data analysis, and supporting documentation.
• Propose tailored quality control guidelines by benefit category and insurance product to support internal training and workflow standardization.

Key Relationships - Direct Manager
Manager/Senior Manager/Senior Expert, Claims Handling

Key Relationships - Direct Reports
Key Relationships - Internal Stakeholders
Internal function Division in company

Key Relationships - External Stakeholders
Policyholders/beneficiaries, insurance agents, medical assessors, and legal documentation providers.

Success Profile - Qualification and Experiences
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.