Life & Complex Claims Manager

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.