Claims Operations Analyst

About the Role

The Claims Operations Analyst serves a dual role within the Property & Casualty Claims Department, combining advanced claims operations analysis with direct management of complex property and casualty claims.

Responsibilities

• Claims Quality, Compliance, and Risk Management
  • Conduct operational and file audits to evaluate compliance with claims handling standards, regulatory requirements, reinsurance reporting obligations, internal procedures, and industry best practices.
  • Monitor claims files to ensure timely excess/reinsurance carrier notification and compliance with required coverage documentation.
  • Ensure reservation of rights letters are issued and documented when appropriate.
  • Review claims for accuracy, completeness, reserve adequacy, coding integrity, and compliance with established standards.
  • Monitor and validate data reported through MMSEA and other regulatory reporting systems.
  • Analyze reserve trends and provide recommendations regarding reserve adequacy, loss projections, and financial exposure.
• Business Analysis and Operational Improvement
  • Analyze claims data to identify trends, emerging risks, loss patterns, and opportunities for operational improvement.
  • Develop and maintain operational reports, dashboards, performance metrics, and analytical tools to support management decision-making.
  • Evaluate workflows, systems, and business processes and recommend improvements to increase efficiency, consistency, and data integrity.
  • Identify and support automation opportunities that improve claims operations.
  • Document business requirements, workflows, system configurations, and process changes.
  • Coordinate testing, validation, and implementation of system enhancements and process improvements.
• Claims Investigation and Management
  • Independently investigate, evaluate, manage, and resolve complex property and casualty claims from inception through closure.
  • Conduct factual and legal investigations to determine coverage, liability, damages, and appropriate claim resolution strategies.
  • Establish, monitor, and adjust claim reserves based on ongoing evaluation of exposure.
  • Estimate litigation costs and evaluate the financial impact of claims.
  • Develop and execute claim strategies that support effective and timely claim resolution.
  • Ensure all claim files are properly documented and administered in accordance with departmental standards and applicable regulations.
• Litigation and Settlement Management
  • Participate in litigation strategy meetings and collaborate with defense counsel regarding claim direction and resolution.
  • Negotiate settlements within delegated authority.
  • Independently negotiate and authorize settlements up to $100,000.
  • Consult with the Claims Manager on settlement authority exceeding delegated limits.
  • Coordinate issuance of releases, payments, settlement agreements, and other claim-related documentation.
• Loss Coding and Coverage Analysis
  • Evaluate and apply appropriate loss coding to accurately reflect claim experience.
  • Assist with complex coverage analysis and documentation.
  • Ensure claims data accurately supports underwriting, actuarial, and financial reporting needs.

Requirements

• Associates degree in a related field.
• Minimum of ten years of experience in handling the full cycle of insurance claims or ten years of progressively responsible experience in insurance claims, risk management, business analysis, or a related field.
• Must have current and valid driver’s license to be able to drive and visit various member locations.
• OR an equivalent combination of education, training, and experience sufficient to successfully perform the essential duties of the job.

Qualifications

• Bachelor’s Degree in a related field (preferred).
• Experience working with claims management systems and reporting tools (desired).