Senior Licensed Claims Specialist

Cover Genius

26d • $60,000 - $70,000 • Remote

About The Position

We are seeking a Senior Licensed Claims Adjuster who will be responsible for
adjudicating regulated travel and emergency medical insurance claims within the
US Travel 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
Trip Cancellation, Trip Interruption, Trip Delay, and complex medical or
high-exposure claims. You will support SLA adherence, uphold audit standards, and provide technical guidance to non-licensed assessors when regulatory
authority or complex policy analysis is required. Combining sound coverage
judgment and disciplined documentation, you will help safeguard claim quality
while maintaining operational efficiency.

You will bring a strong foundation in insurance policy interpretation,
regulatory compliance, and structured claim investigation. The ideal candidate
will have experience managing regulated claim files, issuing formal
determinations, and navigating jurisdictional insurance requirements. You will
be comfortable handling escalated or complex files independently, applying
analytical reasoning, and communicating decisions clearly and professionally.

You will report directly to the Claims Manager, US Travel. This is a fully
remote role, requiring strong time management, accountability, and the ability
to perform effectively within a distributed team environment while maintaining
high standards of quality, compliance, and productivity.

Requirements

• Active U.S. state Adjuster License in good standing (multi-state or reciprocal licenses preferred).
• 5+ years of experience handling regulated insurance claims, DOI Complaints preferably within travel, specialty, or property & casualty lines.
• Strong working knowledge of insurance policy interpretation, coverage analysis, and regulatory compliance standards.
• Demonstrated experience issuing formal coverage determinations and managing complex or escalated claim files.
• Proven ability to manage claim exposure within delegated authority limits and fraud thresholds.
• 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.

Nice To Haves

• Advanced policy interpretation and coverage analysis
• Regulatory compliance and fair claims handling standards
• Formal claim determination drafting and documentation
• Complex claim investigation and evidence evaluation
• Fraud indicator recognition and risk assessment
• Claims management systems and digital workflow platforms
• KPI-driven performance management and SLA adherence
• Multi-jurisdictional licensing awareness (preferred)
• Data accuracy and audit-ready documentation practices

Responsibilities

• Claims Adjudication: Manage end-to-end handling of regulated travel insurance claims, including investigation, coverage analysis, formal determination, claim actions, communications, and payment issuance within delegated authority limits.
• 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 US Travel vertical.

Benefits

• Flexible PTO. Taking time out is important for our teams to enjoy life and stay fresh.
• Employee Stock Options - we want our people to share in our success, we reward them with ownership for their contribution in creating a world-class company.
• 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.

What This Job Offers

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