Domain Expert | Insurance: Claims Processing & Coverage

Factify; United States; Remote; USD 180,000 - 260,000; Full time

Job summary

Factify is seeking a US insurance expert to map how claims are adjudicated and how coverage is interpreted inside US carriers, turning practical judgment into explicit, testable rules. These rules must hold up with adjusters, auditors and state regulators.

You will map end-to-end claims processes, analyze policy forms and endorsements, translate coverage limits into structured rules, build test cases, and collaborate with our Tel Aviv team on ongoing rulebook maintenance.

Qualifications

• 10+ years in insurance at a US carrier, TPA or MGA with deep expertise in claims management and coverage analysis.
• Deep understanding of policy structure, exclusions, conditions, subrogation, and US insurance regulation.
• Experience with process documentation, quality assurance or audit of insurance decisions.
• Ability to distinguish what the policy says from what the organization actually does, and to explain both clearly.
• Availability for regular overlap with our Tel Aviv team.
• Strong written and verbal communication with insurance leaders, executives and engineers.
• Location: Remote (US) with overlap in US Eastern morning hours.

Responsibilities

• Map claims processes end to end: first notice of loss, triage, coverage verification, investigation, adjudication, reserving, settlement and recovery.
• Map other critical insurance processes as customer needs arise, using your own experience of how they run in practice.
• Analyze policy forms, endorsements, exclusions and claims manuals. Identify contradictions and ambiguity between documents and between documents and practice.
• Translate coverage interpretation and authority limits into structured rules, including SIU and fraud indicators, escalation triggers and state-mandated handling timelines.
• Build test cases and golden-label datasets (covered / not covered / refer, with evidence) across lines such as property, auto, health and liability.
• Review agent outputs against how experienced insurance professionals would decide, and document the failure modes.
• Work with customer leaders to ratify and maintain the rulebook over time.

Skills

Insurance industry experience

Claims management

Policy interpretation

Regulatory knowledge

Quality assurance / audit

Communication skills

Remote collaboration

Job description

Description

About Factify

AI agents are starting to make decisions in regulated enterprises, including US banks and insurers. Factify turns an organization's policies, documents and real-world practice into a sealed, executable rulebook that governs how those agents decide. Every decision is traceable, auditable and ratified by the people who own the process.

The role

You will be our US insurance expert. You will map how critical decisions are really made inside US carriers, starting with how claims are adjudicated and how coverage is interpreted, and turn that judgment into explicit, testable rules. Those rules need to hold up with adjusters, auditors and state regulators. As our work expands, you will cover more of the carrier's critical processes.

What you'll do

• Map claims processes end to end: first notice of loss, triage, coverage verification, investigation, adjudication, reserving, settlement and recovery.
• Map other critical insurance processes as customer needs arise, using your own experience of how they run in practice.
• Analyze policy forms, endorsements, exclusions and claims manuals. Identify contradictions and ambiguity between documents and between documents and practice.
• Translate coverage interpretation and authority limits into structured rules, including SIU and fraud indicators, escalation triggers and state-mandated handling timelines.
• Build test cases and golden-label datasets (covered / not covered / refer, with evidence) across lines such as property, auto, health and liability.
• Review agent outputs against how experienced insurance professionals would decide, and document the failure modes.
• Work with customer leaders to ratify and maintain the rulebook over time.

Requirements

• 10+ years in insurance at a US carrier, TPA or MGA, with deep expertise in claims management, claims operations, coverage analysis or insurance compliance.
• Deep understanding of policy structure, exclusions, conditions and subrogation, and of US insurance regulation: state unfair claims settlement practices, NAIC model laws, and state department of insurance requirements.
• Experience with process documentation, quality assurance or audit of insurance decisions.
• The ability to separate what the policy says from what the organization actually does, and to explain both clearly.
• Availability for regular overlap with our Tel Aviv team.
• Clear written and verbal communication with insurance leaders, executives and engineers.
• Location: Remote (US), with regular overlap with our Tel Aviv team (US Eastern morning hours).

Strong advantage

Hands-on experience in any critical process inside an insurer. Every additional process you know from the inside widens the range of customer problems you can solve. Examples:

• Underwriting and risk selection
• Policy administration, endorsements and renewals
• Billing, premium collection and cancellations
• Fraud detection and SIU investigations
• Subrogation, salvage and recovery
• Reinsurance and ceded claims
• Reserving and actuarial processes
• Regulatory filings, market conduct and compliance
• Broker and agent management
• Customer service, complaints and litigation management

Nice to have

• Experience at an insurtech, in a claims-automation program or in a Big 4 insurance practice.
• Exposure to rules engines, core insurance platforms (such as Guidewire) or AI governance.
• CPCU, AIC, ARM or equivalent credentials.