Senior Claims Specialist (Major Claims)

Senior Claims Specialist (Major Claims)

Job Summary

To handle a limited case load of large and or complex life claims and serve as a referral resource for both Life Claims Technicians and Examiners, to ensure timely and equitable settlement and delivery of excellent customer service.

The role involves complex claims assessment for Death / TPD / Critical Illness / Waiver claims, and the incumbent would be tasked to perform complex claims assessment, which includes claims investigation / reinsurance referral / reporting / quality assurance audit / ad-hoc projects as well as system error management with IT.

Key Accountabilities

• Ensure that claims processes and procedures meet state and federal regulatory requirements and that life claims decisions comply with known case law precedents.
• Conduct analysis into life claims activity and produce operational and analytical reports for management.
• Handle insurance department and consumer complaints.
• Work on cases where litigation is anticipated or outside counsel is directly involved in the resolution of a claims issue.
• Review and approve life, disability, critical illness and accelerated benefit payments up to a specified maximum for technicians, examiners & senior examiners.
• Review life claims involving complex, investigative considerations and assist examiners in managing complex cases.
• Evaluate life claims recommended for denial or where reconsideration of earlier action has been requested.
• Summarize pertinent issues and formulate final recommendation to management.
• Consult with Special Investigations Unit, Medical Director, Underwriting department, and Legal department on medical and legal issues related to life claims.
• Maintain record of legal precedents and changes in regulatory and statutory requirements.
• Communicate with Compliance, Law department and outside counsel on litigated claims.
• Assist in preparing responses to interrogatories, and production of documents.
• Assist in preparation of life claims statistical reports and newsletters for internal and field distribution.
• Conduct operational reviews for compliance and quality.
• Counsel with Life Claims staff on changes to practices and procedures in order to maintain compliance with regulatory and statutory changes, case law changes and best practices.

Business Accountabilities

• Monitor and take responsibility for resources/cash, within defined procedures.
• Evaluate and assess costs and customer needs effectively to value and resolve cases within life claims authority limits.
• Identify and comply with the main principles relevant to legal and regulatory controls that govern standard work practices.
• Collect data from well-established sources and prepare reports including commentary and analysis trends to facilitate the resolution of life claims.
• Monitor life claims handling protocol/customer service charter in order to identify opportunities for improvement.
• Provide clear feedback to customers' enquiries and monitor specific issue handling and resolution.
• Resolve operational day-to-day problems referred from other functions of the business, ensuring an efficient and high-quality service is extended to all internal clients.

Job Requirements

• Bachelor's degree and 6 or more years of experience in the claims area OR
• Diploma or equivalent and 8 or more years of experience in the claims area.
• Requires some with strong knowledge of conventional Death/CI/TPD products, medical knowledge, problem solving, customer service skills as well as knowledge of insurance related laws.
• Good communication skills

You are the heart & soul of Zurich!

At Zurich, we like to think outside the box and challenge the status quo. We take an optimistic approach by focusing on the positives and constantly asking What can go right?

We highly value the experience and know-how of our employees and offer a wide range of opportunities across business areas to encourage you to apply for new opportunities within Zurich when you are ready for your next career step.

Let’s continue to grow together!