What are the responsibilities and job description for the Claims Examiner position at The Savings Bank Mutual Life Insurance Company of Massachusetts?
The Mid-Level Life Claims Examiner adjudicates life insurance claims by reviewing, analyzing, investigating, and determining benefit eligibility. The role requires coordination across Underwriting, Customer Service, Legal, and external parties (physicians, attorneys, agents) to deliver timely, compliant claim resolution with excellent service.
Key Responsibilities
- Claim Adjudication & Decisioning
- Review claims to assess validity under policy provisions, riders, waivers, and applicable state/federal regulations.
- Determine if additional documentation or investigation is required; compute benefits payable and interest.
- Approve or deny claims within established authority limits; escalate complex or high dollar claims to senior staff or SIU as needed.
- Investigation & Special Cases
- Initiate and oversee investigations into cause of death (suicide, homicide, accident), misrepresentation, and suspicious cases.
- Coordinate with internal or external investigators, medical examiners, legal counsel, and forensic consultants.
- Evaluate contestable claims and adjudicate based on medical records, underwriting files, and legal review.
- Coordination & Stakeholder Communication
- Maintain professional, courteous relationships with claimants, agents, attorneys, medical providers, legal entities, and government bodies.
- Document and justify claim decisions clearly in writing (letters, memos, internal reports).
- Regulatory, Compliance & Reporting
- Ensure all work is audit-ready, complies with company policies, state laws, and internal quality controls.
- Prepare and file required tax forms, state notices, consent forms, and regulatory filings, as needed.
- Continuous Learning & Improvement
- Maintain up-to-date knowledge of anatomy, pathology, life insurance, legal rulings, and industry best practices.
- Mentor examiners and claim support representatives or support training activities.
- Participate in process improvement, system enhancement, and quality assurance initiatives.
Qualifications & Skills
- Bachelor’s degree (in business, insurance, finance, or related discipline).
- Minimum of 5 years of life insurance claims experience (contestable claims experience is strongly preferred).
- Demonstrated expertise in life insurance policies, riders, underwriting principles, and state regulations.
- Strong analytical, investigative, and decision-making abilities with attention to detail.
- Excellent written and verbal communication, negotiation, and stakeholder management skills.
- Ability to manage a high volume and variety of cases within performance metrics (cycle time, accuracy, backlog).
- Proficient in claims management systems, document management, Excel, and related tools.
- Preferred: Industry credentials or designations (e.g., ALMI, FLMI) or working toward them.
