Senior Claims Oversight Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Review and offer recommendations on high-value, complex, and out-of-authority claims

• Assess coverage determinations, appeals, exceptions, and escalated claims issues

• Identify trends in claims, operational risks, and opportunities for improvement among administrator partners

• Support audits, market conduct examinations, regulatory inquiries, and initiatives for corrective actions

• Oversee administrator adherence to carrier requirements, policies, and regulations

• Assist in investigations related to fraud, reporting, and activities aimed at risk mitigation

• Analyze claims data, audits, and operational metrics to enhance performance and outcomes

• Review workflows, procedures, and controls of administrators for efficiency and compliance

• Collaborate with stakeholders to implement process enhancements and corrective action plans

• Develop and uphold claims guidelines, governance standards, and operational procedures

• Support improvements to claims oversight and governance programs

• Communicate updates on policies, claims guidance, and operational requirements to stakeholders

• Act as a subject matter expert in claims oversight and delegated claims administration

• Provide guidance, training, and support to team members and business partners

• Engage in projects and initiatives that enhance carrier operations and claims governance

⛳️ Requirements

• Over 5 years of experience in insurance claims, claims operations, compliance, quality, or a related field

• Strong understanding of claims handling, coverage interpretation, and regulatory obligations

• Exceptional analytical, problem-solving, communication, and stakeholder management skills

• Preferred: Experience with TPAs, delegated authority programs, or carrier oversight functions

• Preferred: Experience in supporting audits, compliance initiatives, fraud investigations, or process enhancements

• Preferred: Bachelor’s degree in Business, Insurance, Risk Management, or a similar field

🏝️ Benefits

• Comprehensive medical, dental, and vision insurance

• Basic Life Insurance provided at no cost to employees

• Company-funded short-term and long-term disability coverage

• 12 weeks of fully paid Parental Leave

• Health Savings Account (HSA)

• Flexible Spending Accounts (FSA)

• Retirement savings plan

• Personal Paid Time Off

• Paid holidays and a company-wide Wellness Day off

• Paid time off for volunteering at nonprofit organizations

• Pet-friendly office environment

• Commuter Benefits

• Group Pet Insurance

• On-the-job training and skills development

• Employee Assistance Program (EAP)