Claims Officer (For Pooling)

MAIN PURPOSE

OF THE JOB:

The purpose of a Life Claims Officer is to review, assess, recommend, and/or make decisions on individual life insurance or claims originating through strategic partnerships, employee benefits-related life insurance claims submitted by policyholders, employees, beneficiaries, brokers, HR or other authorized parties ensuring accurate and timely settlement while maintaining collaboration with partner organization or distributors.

KEY ACCOUNTABILITIES:

• Reviewing life claims and verifying the accuracy of submitted information
• Assess claims against policy terms, conditions, and exclusions
• Processing claims for payment, ensuring coverage validity and correct coding
• Examining claims for potential fraud or abuse
• Ensure compliance with internal policies, regulatory standards, and statutory requirements.
• Communicating with employees, beneficiaries, and internal stakeholders to answer queries and resolve issues
• Identify and escalate complex or suspicious claims for further review
• Calculate claim payouts and prepare settlement/decision letter
• Maintain detailed records of claim assessments and communications.
• Contribute to continuous improvement of claims processing procedures.
  
  

KEY

STAKEHOLDERS:

Internal: Claims Services, Distribution Services,

External: Network Partners, Clients, Distributors

EXPERIENCE

• Proven experience in processing life insurance of individual and group/partnership claims
• In-depth knowledge of life insurance claims processes and terminology. 
• Excellent communication, interpersonal and negotiation skills to liaise with internal and external stakeholders involved in the claims process.   
• Strong understanding of data privacy, confidentiality, and fraud detection in individual or partner-sourced claims, compliance standards in the insurance sector, and regulatory requirements

QUALIFICATIONS

• A bachelor’s/college degree. Paramedical course is preferred but not required. 
• Certification in insurance (e.g., CPCU, LOMA) is a plus.
• At least 3 years experience in processing life claims, partnership management, or medical or forensic investigations related to claims.
• Strong computer literacy, especially with MS Office applications
• Communication Skills:  Excellent verbal and written communication skills with ability to effectively articulate policy terms and conditions, and claims decision. 
• Problem Solving Abilities:  Strong analytical and problem-solving skills to identify claim processing gaps and recommend effective solutions for implementation. 
• Knowledge of relevant regulations and compliance standards in the insurance sector  including data privacy, anti-bribery and corruption laws. 
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