Licensed Claims Adjuster

Cover Genius • New York, NY

6d • Remote

About The Position

We are seeking a Licensed Claims Adjuster who will be responsible for adjudicating regulated insurance claims within the Digital Commerce vertical. This role sits at the intersection of regulatory compliance, policy interpretation, and operational performance. The position combines traditional claims handling responsibilities—such as conducting investigations, reviewing documentation, interpreting policy language, issuing coverage determinations, and maintaining detailed file documentation—with elevated authority to handle regulated and complex files requiring state licensure. This is not a purely administrative role nor a purely customer service role, but a specialized position designed to strengthen compliance, technical accuracy, and financial risk controls across the claims function. You will collaborate closely with the Claims Manager and cross-functional stakeholders to ensure timely, compliant, and well-reasoned determinations on complex and/or high-exposure claims related to electronics, appliances, furniture, and other retail goods. Combining sound coverage judgment and disciplined documentation, you will help safeguard claim quality while maintaining operational efficiency.

Requirements

• Active U.S. state Adjuster License in good standing (multi-state or reciprocal licenses preferred).
• 2+ years of experience handling regulated insurance claims, ideally across electronics, appliances, or furniture, financial/credit card/NAC programs a plus.
• Strong knowledge of digital commerce and retail supply chain operations, including warranty and service contract programs.
• Familiarity with repair networks and ability to coordinate repair assessments and turnaround processes.
• Solid understanding of jurisdictional insurance regulations and fair claims handling practices.
• Strong analytical and investigative skills with sound judgment in evaluating documentation and determining coverage.
• Excellent written communication skills, particularly in drafting clear, defensible claim determinations.
• Experience working in a KPI-driven environment with accountability for quality and turnaround time.
• Ability to operate independently in a fully remote environment with strong organizational and time-management skills.
• Proficiency in claims management systems and digital documentation platforms.
• Collaborative mindset with the ability to provide technical guidance and support to junior or non-licensed team members.
• Bachelor's degree in a relevant field, A postgraduate degree and/or record of academic achievement is also desirable.

Nice To Haves

• Investigative rigor with ability to verify claims through documentation and repair assessments.
• High attention to detail, ensuring accuracy in case handling and valuation.
• Customer-first approach, resolving escalations with empathy and professionalism.
• Strong analytical skills to spot claim trends, systemic risks, and recurring product issues.
• Confident, timely decision making in complex or high-value cases.
• Clear communication and collaboration skills with retail partners, repair networks, and compliance.

Responsibilities

• Claims Adjudication: Manage end-to-end handling of regulated insurance claims, including investigation, coverage analysis, formal determination, claim actions, communications, and payment issuance related to retail, electronics, appliances, and furniture within defined service-level agreements (SLAs).
• Claim Determination: Interpret policy language and underwriting guidelines to issue compliant, well-reasoned coverage decisions in accordance with applicable state insurance regulations.
• Complex & Escalated Files: Handle high-exposure, sensitive, or escalated claims requiring licensed authority and independent judgment.
• Regulatory Compliance: Maintain active state licensure and ensure adherence to jurisdictional insurance laws, DOI requirements, and internal governance standards.
• Fraud & Risk Identification: Identify potential fraud indicators and escalate appropriately in line with company protocols and fraud thresholds.
• Customer Communication: Respond to customer inquiries via phone, email, or chat regarding claim status, documentation, and coverage decisions, communicating complex determinations clearly and professionally.
• Documentation & Audit Readiness: Ensure all required documentation is collected, reviewed, and accurately recorded in the claims system to support audit integrity and regulatory compliance.
• Quality & KPI Performance: Maintain high levels of claim accuracy and timeliness in alignment with business, team, and individual performance metrics.
• Technical Support & Collaboration: Provide guidance to non-licensed assessors on policy interpretation and complex files; collaborate with Claims, Support, and Compliance teams to ensure efficient and consistent resolution.
• Process Improvement: Identify and recommend operational improvements to enhance efficiency, reduce leakage, and strengthen internal controls within the Digital Commerce vertical.

Benefits

• Flexible Work Environment - our team is remote.
• Global company, with the opportunity to work from any of our offices for 4 weeks a year
• Work with like-minded people who are passionate about both the work we're doing and giving back. Our CG Gives programs enables us to all become philanthropists through our peer recognition and rewards system.
• Social Initiatives

What This Job Offers

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