Domain Expert | Insurance: Claims Processing & Coverage

Factify • New York, NY

14h • Remote

About The Position

Factify is seeking a US insurance expert to map how critical decisions are made inside US carriers and translate that judgment into explicit, testable rules. The initial focus is claims adjudication and coverage interpretation, with rules designed to be acceptable to adjusters, auditors, and state regulators. As customer needs evolve, the role will extend to other critical carrier processes.

The expert will map claims processes end to end; analyze policy documents and claims manuals for ambiguity or contradictions; encode coverage interpretations and authority limits into structured rules; and build test cases and labeled datasets. They will evaluate agent decisions against experienced insurance professionals’ judgment, document failure modes, and work with customer leaders to ratify and maintain the rulebook. The role is remote in the US and requires regular overlap with Factify’s Tel Aviv team during US Eastern morning hours.

Requirements

• 10+ 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 audit 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.
• 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, using practical experience of how those processes operate.
• Analyze policy forms, endorsements, exclusions, and claims manuals to identify contradictions and ambiguities between documents and actual practice.
• Translate coverage interpretations 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 the decisions experienced insurance professionals would make 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