Senior Life Claims Examiner - Complex Claims (Remote)

Legal & General America; Urbana (MD); Remote; USD 81,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus

Long-term incentives

Annual bonuses

Pension plan

401K with company match up to 6%

9 paid holidays

Job summary

Banner Life Insurance Company in Frederick, MD is seeking a Claims Examiner to adjudicate complex life and health claims, including contestable cases and potential fraud. You will provide technical guidance to Claims Representatives and present dispositions to management.

Analyze medical records, underwriting evidence, and policy provisions to determine liability, manage a high-risk caseload, and support litigation and regulatory matters as needed.

Qualifications

• Bachelor's degree or equivalent combination of education and relevant experience preferred.
• Advanced insurance education or credentials such as ALMI, ACS, or comparable coursework preferred.
• ALHC or comparable claims-focused credential preferred.
• Advanced knowledge of life insurance contracts, complex and contestable claims, investigations, and claims procedures required.
• Minimum of three years of progressively responsible life claims experience, including complex claim adjudication.
• Five or more years of general life insurance experience preferred.

Responsibilities

• Independently evaluate and resolve complex, contestable, and higher-risk claims within delegated authority; prepare well-supported recommendations for matters requiring management approval.
• Communicate with claimants, beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners regarding complex claim requirements, status, and resolution.
• Determine and request the documentation, evidence, and investigations needed to adjudicate complex claims.
• Apply policy provisions, applicable law, underwriting evidence, medical information, and administrative records to determine liability and the appropriate settlement.
• Manage pending complex claims within contractual, regulatory, and departmental timeframes, identifying barriers and escalating material risks.
• Document analyses, decisions, and recommendations clearly in the claim file and present cases requiring approval to management.
• Direct and monitor claim investigations performed by third-party vendors; evaluate findings for relevance, completeness, and credibility.
• Analyze medical records, autopsy and toxicology reports, investigative findings, underwriting evidence, and other records to determine liability.
• Manage contestability and rescission reviews, including coordination with underwriting, legal, compliance, and other business partners.
• Support litigation and regulatory matters, including depositions, examinations under oath, and case preparation, as needed.
• Organize complex claim files for legal review and provide concise case summaries, timelines, and supporting documentation.
• Manage reinsurance activity for assigned complex claims, including timely notice, billing, follow-up on recoverables, and system updates.
• Maintain advanced knowledge of claims law, regulations, tax requirements, and industry practices; apply changes to claim decisions and procedures.
• Apply underwriting principles and evidence when evaluating contestability, material misrepresentation, and rescission issues.
• Identify and assess fraud indicators, determine when enhanced investigation is warranted, and elevate suspected fraud in accordance with company procedures.
• Prepare and analyze reporting related to claim settlements, reinsurance recoveries, financial reconciliations, trends, and assigned management initiatives.
• Serve as a technical resource to Claims Representatives by answering case questions, shared specialized knowledge, and assisting with training or quality improvement.
• Lead or support special projects, process improvements, and other complex assignments from management.

Skills

Life insurance claims

Contestable claims

Underwriting knowledge

Analytical skills

Communication skills

Documentation

Microsoft Word/Excel

Education

Bachelor's degree or equivalent

ALMI/ACS or comparable coursework

ALHC or comparable credential

Tools

Claims systems

Microsoft Excel

Document management

Job description

Banner Life Insurance Company in Frederick, MD is seeking a Claims Examiner to adjudicate complex life and health claims, including contestable cases and potential fraud. You will provide technical guidance to Claims Representatives and present dispositions to management.

Analyze medical records, underwriting evidence, and policy provisions to determine liability, manage a high-risk caseload, and support litigation and regulatory matters as needed.