Domain Expert | Insurance: Claims Processing & Coverage

Factify • New-York, NY

20h • Remote

About The Position

Factify is hiring a US insurance expert to map how critical decisions are made inside US carriers and convert that judgment into explicit, testable rules for governing AI agents. The initial focus is claims adjudication and coverage interpretation, with the scope expanding to other critical carrier processes as customer needs arise. The rules must be suitable for use and review by adjusters, auditors, and state regulators. The role is remote in the US and requires regular overlap with the Tel Aviv team during US Eastern morning hours.

Requirements

• 10 or more years of insurance experience 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.
• Understanding of US insurance regulation, including state unfair claims settlement practices, NAIC model laws, and state department of insurance requirements.
• Experience with process documentation, quality assurance, or audits of insurance decisions.
• Ability to distinguish what a policy says from what an organization actually does, and explain both clearly.
• Availability for regular overlap with the Tel Aviv team during US Eastern morning hours.
• Clear written and verbal communication with insurance leaders, executives, and engineers.

Nice To Haves

• Hands-on experience in additional critical insurer processes, such as 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; or customer service, complaints, and litigation management.
• 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.

Responsibilities

• Map claims processes end to end, including first notice of loss, triage, coverage verification, investigation, adjudication, reserving, settlement, and recovery.
• Map other critical insurance processes as customer needs arise, drawing on practical experience of how they operate.
• Analyze policy forms, endorsements, exclusions, and claims manuals; identify contradictions and ambiguity across documents and between documents and actual 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 for covered, not covered, or refer decisions, with supporting evidence, across lines such as property, auto, health, and liability.
• Review agent outputs against decisions made by experienced insurance professionals and document failure modes.
• Work with customer leaders to ratify and maintain the rulebook over time.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed