Claims Examiner, Credit

Fortegra•Jacksonville, FL

6d•Onsite

About The Position

The Credit Claims Examiner is responsible for delivering exceptional customer service while accurately adjudicating Credit Protection and Debt Cancellation claims. This role reviews claim documentation, determines coverage eligibility, and communicates claim decisions in accordance with policy provisions, regulatory requirements, and company guidelines. The position requires balancing claim adjudication with inbound customer service responsibilities based on business needs while maintaining quality, productivity, and compliance standards.

Requirements

High School Diploma or equivalent.
Minimum 2 years’ experience in claims and/or other related claims processes.
Strong customer service experience with the ability to effectively communicate verbally and in writing.
Experience handling confidential information while maintaining accuracy and attention to detail.

Nice To Haves

Experience reviewing documentation and making coverage or eligibility determinations preferred.
Fraud awareness and claims investigation experience preferred.

Responsibilities

Review, evaluate, and adjudicate Credit Protection and Debt Cancellation claims by analyzing submitted documentation and determining the appropriate claim outcome (approve, pend, or deny) in accordance with policy provisions, exclusions, and eligibility requirements.
Accurately enter claim information into multiple systems while maintaining complete and timely claim documentation.
Balance claim adjudication responsibilities with inbound customer service support based on business needs, handling approximately 40–60 inbound calls on designated call days.
Provide professional, empathetic, and solution-focused service to customers, financial institutions, vendors, and business partners regarding claim status, documentation requirements, and coverage decisions.
Navigate multiple software applications simultaneously while maintaining productivity and accuracy.
Investigate claims for potential fraud indicators and escalate concerns in accordance with established anti-fraud procedures.
Obtain, validate, and analyze documentation necessary to support claim decisions.
Maintain audit-ready claim files that support internal quality standards, regulatory compliance, and legal requirements.
Ensure compliance with applicable state regulations, company policies, privacy requirements (including HIPAA where applicable), and internal operating procedures.
Meet established productivity, quality assurance, customer experience, and service level expectations.
Identify opportunities to improve processes, enhance operational efficiency, and elevate the customer experience.
Participate in departmental meetings, training sessions, quality reviews, and continuous learning initiatives.
Provide cross-functional support as needed, serving as a backup resource to other departments across customer service, claim adjudication, and administrative functions to ensure continuity of operations and service levels.