Carrier Senior Claims Oversight Analyst

Accountabilities

Review high-value, complex, and over-authority claims, providing informed recommendations to ensure appropriate handling and alignment with carrier guidelines.
Evaluate coverage determinations, appeals, exceptions, and escalated claims, ensuring decisions are consistent, accurate, and supported by applicable policies and documentation.
Oversee delegated claims operations performed by third-party administrators (TPAs), monitoring compliance with contractual requirements, carrier policies, established procedures, and applicable regulations.
Identify emerging claims trends, operational weaknesses, compliance concerns, and opportunities to improve claims quality and administrative efficiency.
Support internal and external audits, market conduct examinations, regulatory inquiries, and corrective action initiatives to maintain effective claims governance.
Assist with fraud investigations, claims-related reporting, risk assessments, and mitigation strategies to protect operational integrity.
Analyze claims data, quality audit results, performance metrics, and operational reports to identify patterns, assess outcomes, and recommend improvements.
Evaluate administrator workflows, controls, procedures, and quality assurance practices to identify gaps and strengthen compliance.
Collaborate with internal teams and external administrators to develop and implement corrective action plans, improve processes, and resolve recurring claims issues.
Develop, maintain, and update claims handling guidelines, governance standards, operational procedures, and supporting documentation.
Communicate policy changes, coverage guidance, regulatory updates, and operational expectations clearly to administrators, internal stakeholders, and business partners.
Support the ongoing development and enhancement of claims oversight programs, governance frameworks, and quality monitoring processes.
Serve as a subject matter expert on complex claims, delegated authority arrangements, coverage interpretation, and claims administration practices.
Provide guidance, training, and coaching to colleagues and business partners to promote consistent claims handling and strengthen technical capabilities.
Participate in cross-functional projects and strategic initiatives designed to improve carrier operations, strengthen compliance, and deliver high-quality claims outcomes.
Requirements
At least 5 years of professional experience in insurance claims, claims operations, compliance, quality assurance, or a related field.
Strong knowledge of claims handling processes, insurance coverage interpretation, claims evaluation, appeals, and applicable regulatory requirements.
Demonstrated ability to assess complex claims, evaluate exceptions, analyze supporting documentation, and provide sound recommendations based on policy provisions and established guidelines.
Experience overseeing claims quality, monitoring operational performance, identifying compliance gaps, and implementing corrective actions.
Familiarity with third-party administrators, delegated claims authority programs, carrier operations, or insurance oversight functions is highly desirable.
Experience supporting audits, regulatory examinations, compliance initiatives, fraud investigations, risk mitigation, or claims process improvement projects is preferred.
Strong analytical and problem-solving skills, with the ability to interpret claims data, identify trends, evaluate risks, and translate findings into actionable recommendations.
Excellent written and verbal communication skills, including the ability to explain technical claims and coverage matters clearly to internal stakeholders and external partners.
Proven stakeholder management and relationship-building capabilities, with the ability to collaborate effectively across teams and work constructively with third-party administrators.
Strong organizational skills and attention to detail, particularly when managing complex claims, regulatory documentation, audit findings, and competing priorities.
Ability to exercise sound judgment, work independently, manage escalated issues, and make recommendations that balance compliance, risk, operational efficiency, and service quality.
A continuous improvement mindset, with the ability to identify process gaps, support governance enhancements, and promote consistent operational standards.
A bachelor's degree in Business, Insurance, Risk Management, or a related discipline is preferred.
A commitment to professional integrity, accurate documentation, regulatory compliance, and high standards of claims quality.
Benefits
Competitive compensation: Annual base salary ranging from $74,122 to $92,653, depending on relevant experience, skills, certifications, and other job-related factors.
Remote work: Fully remote working arrangement within the United States.
Healthcare coverage: Comprehensive medical, dental, and vision insurance.
Health savings options: Health Savings Account (HSA) and Flexible Spending Accounts (FSA).
Life and disability protection: Basic life insurance at no cost to employees, along with company-paid short-term and long-term disability coverage.
Paid parental leave: Up to 12 weeks of parental leave at 100% pay.
Retirement planning: Access to a retirement savings plan.
Paid time off: Personal paid time off, paid holidays, and a company-wide wellness day.
Community involvement: Paid time off to volunteer with nonprofit organizations.
Employee wellbeing: Access to an Employee Assistance Program (EAP) and additional resources to support personal and professional wellbeing.
Pet-related benefits: Group pet insurance and a pet-friendly workplace environment.
Professional development: On-the-job training, skills development, and opportunities to expand insurance claims and compliance expertise.
Career advancement: Opportunities to contribute to evolving claims governance programs, collaborate across business functions, and grow professionally within a developing insurance organization.
Additional perks: Commuter benefits may be available depending on work location and eligibility.