Carrier Senior Claims Oversight Analyst

<h3>Accountabilities</h3><li>Review high-value, complex, and over-authority claims, providing informed recommendations to ensure appropriate handling and alignment with carrier guidelines.</li><li>Evaluate coverage determinations, appeals, exceptions, and escalated claims, ensuring decisions are consistent, accurate, and supported by applicable policies and documentation.</li><li>Oversee delegated claims operations performed by third-party administrators (TPAs), monitoring compliance with contractual requirements, carrier policies, established procedures, and applicable regulations.</li><li>Identify emerging claims trends, operational weaknesses, compliance concerns, and opportunities to improve claims quality and administrative efficiency.</li><li>Support internal and external audits, market conduct examinations, regulatory inquiries, and corrective action initiatives to maintain effective claims governance.</li><li>Assist with fraud investigations, claims-related reporting, risk assessments, and mitigation strategies to protect operational integrity.</li><li>Analyze claims data, quality audit results, performance metrics, and operational reports to identify patterns, assess outcomes, and recommend improvements.</li><li>Evaluate administrator workflows, controls, procedures, and quality assurance practices to identify gaps and strengthen compliance.</li><li>Collaborate with internal teams and external administrators to develop and implement corrective action plans, improve processes, and resolve recurring claims issues.</li><li>Develop, maintain, and update claims handling guidelines, governance standards, operational procedures, and supporting documentation.</li><li>Communicate policy changes, coverage guidance, regulatory updates, and operational expectations clearly to administrators, internal stakeholders, and business partners.</li><li>Support the ongoing development and enhancement of claims oversight programs, governance frameworks, and quality monitoring processes.</li><li>Serve as a subject matter expert on complex claims, delegated authority arrangements, coverage interpretation, and claims administration practices.</li><li>Provide guidance, training, and coaching to colleagues and business partners to promote consistent claims handling and strengthen technical capabilities.</li><li>Participate in cross-functional projects and strategic initiatives designed to improve carrier operations, strengthen compliance, and deliver high-quality claims outcomes.</li><h2>Requirements</h2><li>At least 5 years of professional experience in insurance claims, claims operations, compliance, quality assurance, or a related field.</li><li>Strong knowledge of claims handling processes, insurance coverage interpretation, claims evaluation, appeals, and applicable regulatory requirements.</li><li>Demonstrated ability to assess complex claims, evaluate exceptions, analyze supporting documentation, and provide sound recommendations based on policy provisions and established guidelines.</li><li>Experience overseeing claims quality, monitoring operational performance, identifying compliance gaps, and implementing corrective actions.</li><li>Familiarity with third-party administrators, delegated claims authority programs, carrier operations, or insurance oversight functions is highly desirable.</li><li>Experience supporting audits, regulatory examinations, compliance initiatives, fraud investigations, risk mitigation, or claims process improvement projects is preferred.</li><li>Strong analytical and problem-solving skills, with the ability to interpret claims data, identify trends, evaluate risks, and translate findings into actionable recommendations.</li><li>Excellent written and verbal communication skills, including the ability to explain technical claims and coverage matters clearly to internal stakeholders and external partners.</li><li>Proven stakeholder management and relationship-building capabilities, with the ability to collaborate effectively across teams and work constructively with third-party administrators.</li><li>Strong organizational skills and attention to detail, particularly when managing complex claims, regulatory documentation, audit findings, and competing priorities.</li><li>Ability to exercise sound judgment, work independently, manage escalated issues, and make recommendations that balance compliance, risk, operational efficiency, and service quality.</li><li>A continuous improvement mindset, with the ability to identify process gaps, support governance enhancements, and promote consistent operational standards.</li><li>A bachelor's degree in Business, Insurance, Risk Management, or a related discipline is preferred.</li><li>A commitment to professional integrity, accurate documentation, regulatory compliance, and high standards of claims quality.</li><h2>Benefits</h2><li>
<strong>Competitive compensation:</strong>Annual base salary ranging from $74,122 to $92,653, depending on relevant experience, skills, certifications, and other job-related factors.</li><li>
<strong>Remote work:</strong>Fully remote working arrangement within the United States.</li><li>
<strong>Healthcare coverage:</strong>Comprehensive medical, dental, and vision insurance.</li><li>
<strong>Health savings options:</strong>Health Savings Account (HSA) and Flexible Spending Accounts (FSA).</li><li>
<strong>Life and disability protection:</strong>Basic life insurance at no cost to employees, along with company-paid short-term and long-term disability coverage.</li><li>
<strong>Paid parental leave:</strong>Up to 12 weeks of parental leave at 100% pay.</li><li>
<strong>Retirement planning:</strong>Access to a retirement savings plan.</li><li>
<strong>Paid time off:</strong>Personal paid time off, paid holidays, and a company-wide wellness day.</li><li>
<strong>Community involvement:</strong>Paid time off to volunteer with nonprofit organizations.</li><li>
<strong>Employee wellbeing:</strong>Access to an Employee Assistance Program (EAP) and additional resources to support personal and professional wellbeing.</li><li>
<strong>Pet-related benefits:</strong>Group pet insurance and a pet-friendly workplace environment.</li><li>
<strong>Professional development:</strong>On-the-job training, skills development, and opportunities to expand insurance claims and compliance expertise.</li><li>
<strong>Career advancement:</strong>Opportunities to contribute to evolving claims governance programs, collaborate across business functions, and grow professionally within a developing insurance organization.</li><li>
<strong>Additional perks:</strong>Commuter benefits may be available depending on work location and eligibility.</li>