Insurance Operations Associate

Role & responsibilities

Job Overview

The Insurance Claims Processor is responsible for reviewing, evaluating, and processing insurance claims submitted by policyholders. This role involves ensuring that claims are handled efficiently, accurately, and in compliance with company policies and regulatory requirements. The ideal candidate will have strong attention to detail, excellent communication skills, and a thorough understanding of insurance policies and procedures.

Key Responsibilities

• Claims Intake & Review

  : Receive, review, and verify incoming insurance claims for completeness and accuracy. Ensure that all required documentation is provided (e.g., claim forms, medical records, invoices, police reports).

• Claims Assessment & Verification

  : Evaluate the validity of claims by assessing the policyholders coverage, the nature of the claim, and any applicable exclusions or limitations in the insurance policy. Verify the claim details with relevant third parties (e.g., hospitals, repair shops, law enforcement agencies) when necessary.

• Data Entry & Record Keeping

  : Accurately input claim details into the insurance management system. Ensure that all information is up-to-date, correct, and complies with company standards and regulatory requirements.

• Claims Investigation

  : Conduct investigations to identify the cause and extent of losses. This may include communicating with policyholders, witnesses, and other stakeholders to gather additional information.

• Approval & Denial Decisions

  : Make decisions on claims based on thorough investigation and review, either approving or denying claims as per policy guidelines and insurance law.

• Communication with Clients

  : Communicate with claimants to explain claim processes, request additional information, and provide updates on claim status. Respond to inquiries regarding policy details, claim eligibility, and outcomes.

• Claims Adjustments

  : If applicable, calculate the value of the claim and determine the appropriate settlement amount in accordance with the policy’s terms and conditions.

• Compliance & Regulations

  : Ensure claims processing complies with all relevant insurance laws, industry standards, and company policies. Maintain confidentiality and handle sensitive information in compliance with privacy regulations.

• Record Maintenance & Reporting

  : Maintain accurate records of all processed claims and provide regular reports to management regarding claims status, trends, and issues.

• Problem Resolution

  : Address and resolve any disputes or issues that arise during the claims process. Work with management and legal teams if necessary to resolve complex claims or disputes.