Claims Escalation Specialist

Job Summary:

The Claims Escalation Specialist is responsible for managing and resolving escalated insurance claims or customer service issues that cannot be resolved at the initial claim handling stage. The role ensures that complex claims are investigated thoroughly, stakeholders are communicated with effectively, and proper resolutions are reached in a timely manner. The specialist will work closely with internal teams, external parties, and customers to ensure customer satisfaction and the efficient resolution of claims.

Key Responsibilities:

1. Escalated Claims Management
   • Review and assess escalated claims that are unresolved at the first level of handling.
   • Act as a liaison between customers, brokers, insurers and senior management to facilitate the resolution of complex claims.
   • Investigate claims that require additional attention or have exceeded established timelines for resolution.
   • Prioritize claims based on urgency, complexity, and potential impact on the organization.
2. Customer Communication
   • Communicate directly with external stakeholders to understand their concerns and provide updates on the status of their concerns.
   • Resolve complaints or issues by offering solutions and setting realistic expectations regarding claim outcomes.
   • Ensure that customers are informed throughout the escalation process and that they feel heard and valued for seamless customer experience.
3. Collaboration with Internal Teams
   • Work closely with internal stakeholders to gather all necessary information and documentation.
   • Coordinate with senior management or specialized teams to resolve escalated claims efficiently.
   • Ensure all teams involved are aligned and working toward a common resolution.
4. Investigation and Analysis
   • Conduct in-depth investigations to gather additional facts, documentation, and evidence for complex or disputed claims.
   • Analyse the claims history, policy terms, and/or any regulations to make informed decisions.
   • Track claim statuses, document decisions, and maintain records of communication.
5. Resolution of Disputes
   • Ensure that the final resolution adheres to company policies, legal requirements, and industry standards.
6. Reporting and Documentation
   • Maintain detailed records of the escalation process, including key decisions, actions taken, and outcomes.
   • Generate regular reports on the status of escalated claims, identifying trends or recurring issues that require attention.
   • Provide management with updates on escalated claims and suggest improvements in claims handling processes.
7. Process Improvement
   • Provide feedback on recurring escalation issues or areas where the claim process can be improved to prevent similar escalations in the future.
   • Suggest process enhancements to reduce the volume of escalated claims and improve customer satisfaction.
   • Participate in training and development programs to stay up to date on industry standards and best practices.
8. Any other ad-hoc projects assigned by the management.

Minimum Requirements:

1. Diploma & above
2. At least 3 years job experience (preferably with claims experience in insurance industry)
3. Good knowledge of group products, and major claims processing.
4. Strong knowledge of group inpatient and outpatient claims processing.
5. Good business writing and communication skill.

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