Claims Examiner

Banner Life family of companies • Frederick, MD

2d • $80,800 - $110,000 • Remote

About The Position

The Claims Examiner independently adjudicates complex and higher-risk life and health claims requiring advanced contractual analysis, including contestable claims, accidental deaths, accelerated death benefits, rescissions, and matters involving potential fraud, litigation, or competing interests. The role provides technical guidance to Claims Representatives, recommends claim dispositions within delegated authority, and presents matters requiring approval to management.

The position evaluates policy provisions, applicable law, underwriting evidence, medical information, investigations, and administrative records to determine liability and settlement. It manages complex claims within contractual, regulatory, and departmental timeframes; coordinates with claimants and internal and external partners; documents analyses and decisions; and supports litigation, regulatory, reinsurance, reporting, and process-improvement work. The Claims Examiner also serves as a technical resource to less-experienced claims staff.

This is a remote opportunity working EST. The expected hiring compensation range is $80,800–$110,000 annually. The position is eligible for the Annual Incentive Plan, with a current target payment of 8% of base salary, subject to corporate and individual performance.

Requirements

• Advanced knowledge of life insurance contracts, complex and contestable claims, investigations, and claims procedures.
• At least three years of progressively responsible life claims experience, including complex claim adjudication.
• Demonstrated proficiency in complex claims, including contestable, accidental death, accelerated death benefit, waiver, foreign death, rescission, and fraud-related matters.
• Advanced organization and prioritization skills, including the ability to manage a complex caseload and competing deadlines.
• Excellent written and verbal communication skills, including the ability to explain complex decisions clearly and professionally.
• Sound independent judgment and decision-making within delegated authority.
• Advanced problem-solving, analytical, investigative, and negotiation skills.
• Advanced product knowledge and ability to interpret contract provisions, underwriting evidence, medical records, and applicable requirements.
• Diplomacy and customer focus when working with beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners.
• High attention to detail and consistent, well-supported claim documentation.
• Strong analytical and technical skills, including the ability to synthesize information from multiple sources.
• Ability to collaborate cross-functionally and provide technical guidance or training to less-experienced claims staff.
• Proficiency in Microsoft Word and Excel and in claims administration and research systems.

Nice To Haves

• Bachelor’s degree or equivalent combination of education and relevant experience.
• Advanced insurance education or credentials, such as ALMI, ACS, or comparable coursework.
• ALHC or a comparable claims-focused credential.
• Five or more years of general life insurance experience.

Responsibilities

• Independently evaluate and resolve complex, contestable, and higher-risk claims within delegated authority, and prepare recommendations for matters requiring management approval.
• Communicate with claimants, beneficiaries, attorneys, agents, reinsurers, vendors, and internal partners about 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 settlement.
• Manage pending complex claims within contractual, regulatory, and departmental timeframes; identify barriers and escalate material risks.
• Document analyses, decisions, and recommendations in claim files and present cases requiring approval to management.
• Direct and monitor third-party claim investigations and 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 in 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 case summaries, timelines, and supporting documentation.
• Manage reinsurance activity for assigned complex claims, including timely notice, billing, recoverable follow-up, and system updates.
• Maintain advanced knowledge of claims law, regulations, tax requirements, and industry practices, and 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 escalate suspected fraud according to company procedures.
• Prepare and analyze reporting related to claim settlements, reinsurance recoveries, financial reconciliations, trends, and management initiatives.
• Serve as a technical resource to Claims Representatives by answering case questions, sharing specialized knowledge, and assisting with training or quality improvement.
• Lead or support special projects, process improvements, and other complex assignments from management.

Benefits

• Health, life, and dental insurance.
• 401(k) with company match up to 6%.
• Pension package.
• 15 vacation days accrued bi-weekly.
• 10 sick days accrued bi-weekly.
• 9 paid holidays throughout the calendar year.
• Wellbeing initiatives.
• Professional development support and mentoring.
• Paid time off to volunteer.
• Eligible for the Annual Incentive Plan; current target payment is 8% of base salary, modified for corporate and individual performance.
• Potential sign-on bonus and long-term incentives.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior