Remote Insurance Claims Expert: Rules & 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

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.