1. Technical Claims Operations
- Perform technical assessments of complex claims, including death benefits, critical illness, accident coverage, and waiver-of-premium cases, with thorough review of policy terms and supporting documents.
- Validate key documents such as medical records, death certificates, accident reports, and legal statements, ensuring compliance with the benefit conditions.
- Identify exclusions, disputes, or risk indicators within claims files and recommend resolution strategies or escalation actions when appropriate.
- Collaborate with the medical review unit to interpret complex health records or lab results that may impact payout decisions.
- Serve as an internal quality reviewer (peer reviewer) for cases flagged for potential fraud, discrepancies, or requiring in-depth evaluation.
- Provide technical guidance to junior staff and peers on handling special cases or incorporating updated product or policy criteria.
- Work jointly with Legal to assess claims involving beneficiary disputes, fraud risk, or confidentiality restrictions.
- Track operational KPIs such as average turnaround time, supplemental documentation requests, and rejection rates, offering insights to optimize performance and reduce complaints.
- Propose enhancements to forms, evaluation checklists, and expert commentary frameworks to streamline decision-making and improve accuracy.
- Draft professional, transparent customer and agent correspondence for cases requiring clarification, additional verification, or declined outcomes, aligning with company policies.
- Support data reconciliation efforts between paper documentation and system entries, ensuring consistency for internal audit and reinsurance purposes.
- Maintain secure records and contribute to internal case libraries by documenting notable technical issues and best practices for team reference and training.
