Claims SME

Job Title: Sr. Claims Analyst / Subject Matter Expert (SME)

Domain: Property & Casualty (P&C) Insurance

Reports To: Claims Team Lead / Operations Manager

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ROLE OVERVIEW

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The Sr. Claims Analyst / SME is a seasoned claims professional who combines deep end-to-end claims expertise with a quality and governance mindset. Acting as the go-to domain authority within the team, this role bridges frontline claims handling and quality assurance — supporting accuracy, compliance, and continuous improvement across the claims lifecycle. The SME also serves as a key escalation point, mentor, and process champion for junior analysts.

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EXPERIENCE REQUIRED

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• 7+ years of end-to-end claims handling experience in P&C Insurance.

• Proven experience in claims quality reviews, audits, or compliance validation.

• Prior experience in a mentoring, coaching, or informal leadership capacity preferred.

• Exposure to transitions, SOP development, or process improvement initiatives is an advantage.

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KEY RESPONSIBILITIES

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Claims Handling & Oversight

• Manage complex and high-value P&C claims from FNOL (First Notice of Loss) through to final settlement.

• Review claim documents, verify policy coverage, limits, deductibles, and liability decisions.

• Conduct thorough claims investigations and provide recommendations on coverage and settlement.

• Act as an escalation point for complex, disputed, or high-risk claims.

• Ensure all claims are processed accurately, within agreed SLAs and compliance requirements.

Quality, Compliance & Governance

• Conduct periodic quality audits and file reviews to ensure accuracy, consistency, and regulatory compliance.

• Evaluate coverage decisions, claim investigations, and settlement outcomes for quality benchmarks.

• Identify process gaps, errors, and improvement opportunities; recommend and implement corrective actions.

• Prepare quality scorecards, audit reports, and performance dashboards for Team Leads and management.

• Assist in maintaining and updating SOPs, quality guidelines, and claims handling frameworks.

SME & Knowledge Management

• Serve as the primary domain expert and go-to resource for claims queries, coverage interpretation, and best practices.

• Support onboarding, training, and upskilling of new and junior claims analysts.

• Provide structured feedback and coaching to improve team performance and claims quality.

• Contribute to knowledge base creation, training materials, and process documentation.

• Represent the claims function in process transitions, client discussions, and internal working groups.

Collaboration & Stakeholder Coordination

• Coordinate with customers, adjusters, brokers, carriers, and internal teams to facilitate smooth claim resolution.

• Partner with the Team Lead on capacity planning, work allocation, and workload management.

• Communicate claim status updates, escalations, and quality findings to relevant stakeholders.

• Support continuous improvement and transformation initiatives across the claims function.

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SKILLS REQUIRED

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Technical Skills

• Deep knowledge of P&C insurance claims processes, coverage types, policy interpretation, and regulatory requirements.

• Strong analytical and investigative capabilities with attention to detail.

• Proficiency in claims management systems, MS Office (Excel, Word, PowerPoint), and reporting tools.

• Sound understanding of quality frameworks, compliance standards, and audit methodologies.

Soft Skills

• Excellent written and verbal communication skills with the ability to explain complex claims concepts clearly.

• Strong problem-solving skills and sound judgement in ambiguous or high-stakes situations.

• Coaching and mentoring ability with a collaborative team-first mindset.

• Ability to manage multiple priorities, meet deadlines, and maintain accuracy under pressure.

• Self-driven and capable of working independently as well as within cross-functional teams.

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KEY PERFORMANCE INDICATORS (KPIs)

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• Claims processing accuracy and quality audit scores.

• SLA adherence and turnaround time on assigned claims.

• Reduction in errors, rework, and escalations within the team.

• Effectiveness of coaching, training, and knowledge transfer activities.

• Timely delivery of quality reports, scorecards, and process documentation.