Claims Examiner

About This Role

Determining and requesting the documentation, evidence, and investigations needed to adjudicate complex claims is a core part of this role. The Claims Examiner independently adjudicates complex and higher-risk life and health claims that require advanced contractual analysis, including contestable claims, accidental deaths, accelerated death benefits, rescissions, and claims involving potential fraud, litigation, or competing interests. This role provides technical guidance to Claims Representatives, recommends claim dispositions within delegated authority, and presents matters requiring approval to management.

Responsibilities

• Independently evaluate and resolve complex, contestable, and higher-risk claims within delegated authority
• Prepare well-supported recommendations for matters requiring management approval
• Communicate with claimants, beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners regarding complex claim requirements, status, and resolution
• Determine and request the documentation, evidence, and investigations needed to adjudicate complex claims
• Apply policy provisions, applicable law, underwriting evidence, medical information, and administrative records to determine liability and the appropriate settlement
• Manage pending complex claims within contractual, regulatory, and departmental time frames, identifying barriers and escalating material risks
• Document analyses, decisions, and recommendations clearly in the claim file and present cases requiring approval to management
• Direct and monitor claim investigations performed by third-party vendors
• Evaluate findings for relevance, completeness, and credibility
• Analyze medical records, autopsy and toxicology reports, investigative findings, underwriting evidence, and other records to determine liability
• Manage contestability and rescission reviews, including coordination with underwriting, legal, compliance, and other business partners
• Support litigation and regulatory matters, including depositions, examinations under oath, and case preparation, as needed
• Organize complex claim files for legal review and provide concise case summaries, timelines, and supporting documentation
• Manage reinsurance activity for assigned complex claims, including timely notice, billing, follow-up on recoverables, and system updates
• Maintain advanced knowledge of claims law, regulations, tax requirements, and industry practices
• Apply changes to claim decisions and procedures
• Apply underwriting principles and evidence when evaluating contestability, material misrepresentation, and rescission issues
• Identify and assess fraud indicators, determine when enhanced investigation is warranted, and elevate suspected fraud in accordance with company procedures