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Location: 

Boston, MA, US

Claims Specialist

 

About iptiQ
 

iptiQ is a risk tech start-up within Swiss Re Group. Swiss Re is one of the world’s leading providers of reinsurance, insurance and other forms of insurance-based risk transfer. We anticipate and manage a wide variety of risks, from natural catastrophes and climate change to cybercrime.

iptiQ provides digital, bespoke and transparent L&H and P&C protection products in a B2B2C manner. Founded in 2014, we're transforming the way consumers buy insurance with a unique digital insurance engine which incorporates the latest technology with world-class underwriting capabilities. We build strong partnerships to sell insurance via trusted brands.

iptiQ offers a flexible working environment where curious and adaptable people thrive. Are you interested in joining us?

 

About the Role:

 

The Claims Specialist will be responsible for the oversight of Third-Party Administrators (TPA) and other outsourced Administrator’s Claim processing to ensure that iptiQ Americas' processes are followed and are within regulatory requirements. The position is required to provide support on claims processing for Life, Medicare Supplement (MedSup), and Critical Illness products. You may also be asked to support the Claims Manager on various initiatives within iptiQ Americas, including the testing for new Lumico Distributors and products, in addition to new Carrier Solutions' relationships.

The position includes responsibility for assuring accuracy of financial reports and reconciliations. Additional responsibilities might include assisting in the oversight of Market Conduct Exams, as well as leading all aspects of any remediation activities or related products. The Claims Specialist may also be asked to support Legal and Compliance staff in answering questions regarding Claim procedures, regulations and specific Claim cases.

 

 

As the Claims Specialist for iptiQ Americas you will be expected to:

 

  • Assure department procedures and controls are followed in the adjudication of all direct life claims. Work with iptiQ Americas' Compliance, Legal and other areas of iptiQ Americas in the performance of assigned duties.
  • Oversee TPAs to ensure that processes are within regulatory requirements and iptiQ America's standards through daily review of claims, reports and periodic on-site reviews of the various sites. Insure that TPA processes are appropriate, properly controlled and in compliance with contractual service level agreements, and all financial reports are accurate and appropriate.
  • Manage and facilitate the approval of claims over the approval authority of the TPAs.
  • Take ownership of the resolution of beneficiary entitlement issues that arise collaborating with iptiQ America's Legal and Compliance areas as necessary.
  • Interpret and apply contract language and applicable law to the claim facts and real-life situations for proper claim adjudication.
  • Oversee and lead investigation of claims for eligibility and entitlement in a timely and efficient manner by evaluating medical records, court and police documents, avocation, financial and other critical information to resolve validity of claim.
  • Understand capabilities of specific vendor to effectively handle specific types of investigations and monitor cost associated with such investigations.
  • Establish personal contact with the policy holder/beneficiary by phone or letter as needed to bring claim to appropriate resolution. All matters regarding claim handling should be thorough, understandable and properly documented.
  • Evaluate the appropriateness of the payment, denial, calculation of the benefits, etc. on each claim, as well as the appropriateness of the TPA’s handling of each claim reviewed.
  • Handle claims to ensure compliance with plan provisions. Also, authorize waiver of premium claims pursuant to a disability plan as needed.
  • Demonstrated understanding of the state and federal compliance regulations including the California Good Faith Claim Handling regulations and our Corporate Privacy policy by investigating claims in accordance with the spirit, intent, and timeliness contained in these documents. Complete annual California Good Faith Claim handling regulations, fraud prevention and privacy training.

 

Additional responsibilities may include:

 

  • Work with staff to ensure department objectives are met.
  • Assist the Claim Manager with assigned projects, site audits and in maintaining the appropriate control and risk documents.
  • Review procedure documents maintained by administrators for appropriateness and accuracy.
  • Collaborate with colleagues of iptiQ Americas to defend claims that are not due to claimants.
  • Assist the Claim Manager with management of Proof of Existence (POE) related projects with responsiveness to state reporting requirements and related TPA processes.
  • Provide assistance on claim processing as directed by the Claim Manager.

 

About You

  • The ideal candidate will have a BS degree or equivalent and a minimum of 8 years of direct individual Claims experience.
  • Claim experience with various insurance types (Life, DI, Health, and MedSup) is preferred.
  • Expertise in Life claim adjudication (working knowledge of compliance and general regulations as they relate to insurance policies and the industry).
  • Past approval authority of a minimum of $500,000, with the ability to have authority increased to $1.5 million.
  • Strong written and verbal communication skills (ability to communicate effectively and professionally with policy holders, beneficiaries, agents, attorneys, TPAs or any other source necessary to obtain specific information or explain claim decisions or handling procedures).
  • Ability to utilize good judgment when reacting to areas of claim handling that can lead to extra-contractual litigation, insurance department inquires or consumer agency action to the detriment of the company.
  • Ability to handle multiple priorities/predilection to detail.
  • Strong organizational, analytical and computer skills preferred.
  • Familiarity of AWD, Cyberlife, Microsoft Word and Excel is highly preferred.
  • ALHC designation is highly preferred.
  • Basic understanding of reinsurance concepts.

Additional Information

  • Decision making authority is extensive and comprehensive on contestable, accidental, premium waiver and critical illness claims. This position includes extensive latitude and decision making with large exposure claims and litigation potential. Incumbent will have approval limit up to $750,000.
  • Position will be responsible for significant TPA sites. The department oversees multiple processes utilizing multiple life administration and claim systems.
  • Position requires travel up to 35%.

 

Swiss Re is an equal opportunity employer. It is our practice to recruit, hire and promote without regard to race, religion, color, national origin, sex, disability, age, pregnancy, sexual orientations, marital status, military status, or any other characteristic protected by law. Decisions on employment are solely based on an individual's qualifications for the position being filled.

During the recruitment process, reasonable accommodations for disabilities are available upon request. If contacted for an interview, please inform the Recruiter/HR Professional of the accommodation needed.

 

Keywords:  
Reference Code: 103630 


Nearest Major Market: Boston

Job Segment: Claims, Underwriter, Law, Compliance, HR, Insurance, Legal, Human Resources