Job Summary

The Life & Complex Claims Manager provides leadership and technical oversight for a specialized team of Claim Examiners handling life insurance, contestable investigations, foreign deaths, complex legal requests, and living benefit rider claims (Critical, Chronic, and Terminal Illness).This role is responsible for ensuring rigorous investigative standards, accurate contractual interpretation, and sound risk mitigation while delivering compassionate, transparent service to beneficiaries and partners.The Manager leads the operational execution of the Complex Claims Roundtables, acts as a primary liaison with Legal and Underwriting and drives continuous process optimization to reduce cycle times and mitigate risk.

Duties & Responsibilities

• Claim Approval & Adjudication: Provide secondary review and financial approval on life claims, contestable investigations, policy rescissions and living benefit rider claims within established authority limits.
• Contestable Investigation Oversight: Direct end-to-end medical investigation during the contestability period, ensuring adherence to claim guidelines, and state-specific fair claims practices.
• Lead and facilitate the weekly Complex Claims Roundtable, collaborating with Underwriting, Legal, and Compliance to evaluate high-risk or litigated files and serve as the primary point of claim escalation for complex claims, appeals, contested denials, and state insurance Department/regulatory inquiries, ensuring decisions are thoroughly reasoned and documented. Occasionally communicate directly with claimants/agents on specific claim cases and escalations.
• Vendor & Partner Oversight: Manage operational workflows with specialized external partners, including Independent Medical Examination (IME) providers. Partner with Functional Capacity Evaluation (FCE) vendors, retrieval services, investigation partners, and reinsurers.
• Technical Coaching: Actively mentor and upskill specialized examiners in advanced investigative techniques, medical record analysis, fraud indicators, contractual policy provisions, and other claim technical skills.
• Performance Management: Establish and monitor quantitative and qualitative metrics (e.g., investigative cycle time, audit quality, aged pending) through structured 1:1s, documented development plans, and timely corrective action when needed.
• Capacity & Demand Planning: Manage workload allocation and queue segmentation across complex workflows, balancing examiner caseloads to maintain SLA compliance and prevent aged inventory.
• Regularly evaluate complex claim workflows, letters, and forms (e.g., Attending Physician Statements, Living Benefit intake forms) to eliminate operational bottlenecks, reduce cycle times, and improve customer experience. Provide oversight of comprehensive standard operating procedures (SOPs), job aids, and training documentation for life, living benefit, and complex claim adjudication. Leverage claims data and Business Intelligence dashboards to identify root causes of claim delays, quality trends, and fraud patterns, presenting actionable insights to senior leadership.
• Oversee all aspects of the life and complex Claims functions, ensuring operational compliance with state and industry regulations.
• Model and maintain a strong culture of accountability and transparency at all levels of the department, taking ownership of decisions, outcomes, successes, and challenges. Oversee quality review and control processes for all claims activities. Ensure appropriate claims governance, including authority levels, escalation protocols, and proactive identification and mitigation of risk issues or events to minimize impact and recurrence.

Supervisory Responsibilities:  This role has people leadership responsibilities, including managing performance, developing talent, and supporting engagement and team effectiveness.

Knowledge, Skills & Abilities

• Critical Thinking & Analytical Rigor: Exceptional ability to synthesize dense medical records, legal documents, trust agreements, and historical application data to make sound claim decisions.
• Contractual & Regulatory Acumen: Experience with state contestability statutes, unfair claims settlement practices regulations, HIPAA standards and policy rider language.
• Communication: Ability to communicate complex medical, technical, and legal determinations clearly, professionally, and empathetically with claimants, sales partners, legal counsel, and senior leadership.
• Decisive Leadership: Proven track record of addressing performance and behavioral gaps directly, fostering a culture of ownership, continuous learning, and high accountability.
• Cross Functional Collaboration: Skilled at building strong partnerships with internal stakeholders across Underwriting, Legal, Compliance, Operations Controls, and Distribution Partners.
• Strong life and/or disability claim expertise, with in-depth knowledge of contestable and accelerated benefit claims.
• Ability to establish goals, structures, and processes that translate strategic vision into clear team objectives and measurable outcomes.
• Maintains current knowledge of life and annuity regulations, including state claims handling requirements, unclaimed property laws, and evolving compliance obligations.

Minimum Qualifications

• Bachelor's degree preferred (or equivalent professional experience)
• 5+ year of relevant experience
• 5+ years of progressive claims adjudication experience in Life, Disability, Contestable, and/or Living Benefit Riders Claims (Critical/Chronic Illness).
• 2+ years of direct people leadership or proven technical supervisory/mentorship experience within a specialized claims environment.
• Combination of education and experience considered in lieu of degree.
• Professional designations through LOMA (e.g., FLMI, ALMI) or the International Claim Association (ICA) (e.g., FLHC) preferred.
• Experience in Lean, Six Sigma, or continuous process improvement methodologies is preferred.

Other Requirements

• This position primarily involves sedentary work, requiring long periods of sitting, regular use of a computer, and occasional standing or walking, with reasonable accommodations available.
• Perform other functions, duties and projects as assigned
• Regular and punctual attendance

Ability to travel up to:  10% of the time

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