Senior Claim Examiner

We are seeking an experienced and detail-oriented Senior Claim Examiner to manage an assigned caseload and serve as a primary point of contact throughout the claim’s lifecycle. This role is responsible for reviewing, evaluating, and processing claims while providing clear guidance and support to policyholders, providers, and internal partners.

The ideal candidate will demonstrate strong analytical skills, sound judgment, and strong verbal and written communication skills, including exceptional phone communication abilities. This position requires the ability to confidently handle complex conversations, clearly explain coverage determinations, accurately document claim activity, and read, interpret, and apply insurance contract provisions when making claim decisions. Success in this role requires adaptability, accuracy, and the ability to manage changing workloads in a fast-paced environment.

• Manage an assigned claims caseload on an ongoing basis, ensuring timely and accurate processing

• Review, analyze, and adjudicate claims according to policy provisions and company guidelines

• Communicate claim decisions, requirements, and next steps clearly and professionally via phone

• Handle complex or escalated claim situations with confidence and sound judgment

• Maintain consistent follow-up with policyholders, beneficiaries, providers, and internal departments

• Document all claim activity thoroughly and accurately in the claims management system

• Interpret policy language and explain coverage determinations in a clear, understandable manner

• Identify potential issues, discrepancies, or risks and escalate as appropriate

• Maintain compliance with regulatory requirements and internal quality standards

• Meet productivity, quality, and service level expectations

• High school diploma required; associate or bachelor’s degree preferred

• 2+ years of claims handling experience or related insurance industry experience preferred

• Strong knowledge of insurance policies, claims processes, and regulatory requirements

• Strong written and verbal communication skills, including the ability to explain complex information clearly and manage sensitive conversations professionally

• Ability to demonstrate critical thinking skills to evaluate claims accurately and consistently

• Ability to manage an assigned caseload with a high level of accuracy, organization, and time management

• Ability to work effectively in a fast-paced environment with shifting priorities Ability to handle confidential information with discretion and professionalism

• Proficiency in claims systems and/or standard business software

• Demonstrate ability to work independently and collaborate effectively with internal teams