CLAIMS ASSESSOR JOB DESCRIPTION

A Claims Assessor determines whether a policyholder's submission meets coverage criteria and authorises payment within defined authority limits. Accurate. That one-word standard governs everything. In insurance lines ranging from income protection and total and permanent disablement to travel and warranty products, the assessor interprets policy terms, validates medical and financial evidence, and applies regulatory frameworks such as the Insurance Contracts Act and LICOP to reach decisions that are both defensible and fair. The role sits within a claims operations team, answering directly to a Claims Assessment Manager, and its output shapes the financial exposure the organisation carries on every open file.

As the Claims Assessor, you evaluate incoming claims against policy terms, regulatory requirements, and documented evidence to authorise accurate, timely payments that protect both the customer and the organisation's financial position. You operate within a structured claims team where your decisions feed directly into SLA reporting, fraud controls, and quality-assurance audits conducted by senior assessors and team leaders.

Career Impact: Developing technical proficiency across life, health, and group insurance product lines, combined with applied knowledge of regulatory instruments such as LICOP and RG271, establishes the credentials that advance a career into senior assessment or claims management.

Business Impact: Every decision you make directly determines the accuracy of claim payments, the organisation's leakage exposure, and the claimant experience measured through quality listening scores and customer survey results.

Growth Opportunity: Assessors who demonstrate regulatory fluency and caseload ownership regularly progress into Review Officer, Claims Team Leader, or specialist fraud and compliance roles within the same organisation.

• Assess incoming claims against policy terms, financial evidence, and medical documentation to reach accurate payment decisions within delegated authority.
• Validate policyholder eligibility, premium status, and coverage dates before recording outcomes in the claims management system.
• Investigate potential fraud indicators across claims files, escalating complex or high-risk cases to senior assessors or compliance teams.
• Resolve customer enquiries and complaints relating to claim decisions within agreed service timeframes, keeping claimants informed at each stage.
• Prepare decision reports and correspondence that document the evidentiary basis, applicable legislative instruments, and recommended payment amounts.
• Coordinate with external parties including treating medical practitioners, rehabilitation providers, independent examiners, and insolvency practitioners to gather outstanding claim information.
• Monitor caseload against SLA targets and minimum performance standards, flagging workflow issues to the Claims Assessment Manager.
• Participate in internal claims forums, audits, and quality reviews to maintain accuracy standards across the team.

• Bachelor's degree in business, finance, law, or a related discipline, or equivalent work experience.
• Two or more years of claims assessment or insurance operations experience, with demonstrated ability to interpret policy terms and apply regulatory requirements.
• Proven ability to evaluate financial, medical, and legal documentation to reach and record sound decisions under defined procedures.
• Strong written communication skills, including the ability to produce clear decision letters and evidence summaries for claimants and internal reviewers.
• Sound analytical and problem-solving skills with the ability to manage competing priorities across an active claims portfolio.
• Demonstrated customer service orientation, with experience resolving complaints and managing claimant expectations through complex or sensitive cases.
• Familiarity with insurance compliance obligations including privacy, data integrity, and fraud-control requirements.

• ANZIIF, ALUCA, or FLHC certification, or active progress toward a recognised insurance or life claims qualification.
• Experience assessing claims under group or retail life insurance products including income protection, total and permanent disablement, or trauma cover.
• Working knowledge of legislative instruments relevant to claims decisions, such as the Insurance Contracts Act, LICOP, or equivalent regulatory frameworks.
• Prior exposure to SLA-driven claims environments with quality assurance monitoring and team-level performance reporting.

• Claims accuracy rate, measured against quality assurance audits and minimum business unit performance standards.
• Average handling time per claim, tracked against SLA targets set by the Claims Assessment Manager.
• Leakage rate across managed files, reflecting the adequacy of evidence validation and payment controls.
• Fraud identification rate, measuring the proportion of referred cases that result in confirmed fraud findings.
• Customer survey score or quality listening rating, tied to the resolution of claimant enquiries and complaint handling.
• Complaint resolution rate within agreed timeframes, as reported through the team's compliance and reporting function.
• Typical tools: Claims management platforms (commonly Guidewire or similar); document management and correspondence systems (commonly Microsoft Office suite).

• Base Salary Range: $48,000 to $72,000 annually, depending on seniority and product line specialisation
• Bonus: Performance-based, typically 5 to 10 percent of base tied to accuracy and SLA metrics
• Equity: Not standard at this level in insurance operations roles
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by carrier
• PTO: 15 to 20 days annually, plus standard public holidays
• Common Perks: Professional development funding toward ANZIIF or equivalent certification; employee assistance programs

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background screening, including criminal history and, where applicable, credit history review, is a condition of employment for this role given its access to sensitive financial and medical claim information. All qualified applicants will receive consideration for employment without discrimination on the basis of race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the application and employment process upon request. Candidates must be authorized to work in the United States.

The Claims Assessor owns the full administrative lifecycle of legal matters, from file opening through closure, supporting the legal team with court document preparation, correspondence, and client-facing communications. Reporting to the legal team and collaborating with legal team members, the role delivers an organised, client-centred service that enables the team to obtain maximum compensation for clients.

Key Responsibilities

• Support the legal team with administrative tasks and optimise the use of internal systems to process information.
• Cultivate strong relationships and trust through empathy, interpreting client needs and connecting them with the right legal team members.
• Apply a keen eye across general filing, photocopying and archiving management to spot opportunities for improvement.
• Respond to inbound calls, couriers and emails from clients, ensuring they feel looked after and heard.
• Assist with preparing matters for conference and hearing, including preparation of court documents and general correspondence.
• Provide chargeable and non-chargeable support to the legal team with general administrative duties from file opening to closure.

Required Qualifications

• Previous administration or business support experience.
• Intermediate proficiency in Microsoft Word and Excel with accurate typing skills.
• Strong attention to detail in document management and collation.
• Excellent verbal and written communication skills.
• Naturally empathetic with a genuine passion for helping people.

Embedded within the claims team, the Claims Assessor ensures travel claims are processed and maintained correctly, including ongoing auditing and quality control to deliver seamless customer transactions. Working closely with outsourced partner teams and internal stakeholders, the role advances accurate, regulation-compliant outcomes that meet or exceed business unit performance standards.

Core Functions

• Handle day-to-day claims activities including claims actions, emails, and payments.
• Interact with customers to resolve claims and process payments.
• Assess and approve new claims within delegated authority.
• Interact with outsourced partner teams to coordinate claim outcomes.
• Maintain current knowledge of insurance guidelines, policy changes and regulations.
• Ensure the quality, accuracy and detail of claims assessment meets or exceeds minimum performance standards.

Qualifications & Experience

• High school diploma or equivalent required; with a Bachelor's degree preferred.
• Experience in insurance claims management is highly regarded.
• Ability to adapt quickly to a fast-paced environment and culture.
• Strong problem-solving skills with the ability to advocate for customer solutions.
• Proven ability to build and develop relationships with internal and external stakeholders.
• Fluency in English and Korean, verbal and written.

Reporting to the claims operations team, the Claims Assessor receives, evaluates, and resolves warranty claims submitted electronically, following defined procedures to ensure accurate and timely resolutions. Partnering with dealer networks and internal stakeholders, the role produces consistent claim outcomes that uphold documentation standards and transfer unresolved cases to the appropriate responsible party.

Primary Duties

• Assess and process warranty claims submitted electronically.
• Resolve dealer issues and answer questions submitted through an electronic communication system.
• Receive and assess claims according to defined procedures and routines.
• Perform claim assessment and follow defined procedures to resolve correctly.
• Verify documents and customer information in the data capture tool and transfer claims to the responsible party when needed.

Skills & Qualifications

• A bachelor's degree is considered an advantage.
• Up to one year of work experience.
• Fluency in Spanish and good command of English at B2 level.
• Ability to solve urgent matters and work under pressure.
• Reliable and proactive approach to entrusted tasks with strong attention to detail.
• Strong team player with communication skills across all staff levels.

Sitting at the intersection of customer service and compliance operations, the Claims Assessor delivers performance against Key Performance Indicators while resolving complaints and managing claims to mitigate leakage risk. Operating across the claims function and measured through customer survey results, verbatim feedback, and Quality Listening, the role shapes an effortless claims experience for customers.

Duties

• Deliver performance against business Key Performance Indicators.
• Take ownership of every call and be accountable for outcomes.
• Address and resolve customer complaints associated with the claims function within agreed timeframes.
• Accurately record and manage customer claims to mitigate risk of leakage.
• Provide an effortless claims experience measured through customer survey results, verbatim feedback and Quality Listening.

Experience & Qualifications

• Proven customer service experience.
• Previous experience in insurance is desirable but not essential.
• Sound computer and literacy skills.
• Well-developed interpersonal and communication skills with the ability to build rapport.
• Ability to prioritise and manage time effectively.

A key member of the claims operations team, the Claims Assessor serves as the first point of contact for claimant enquiries, validating financial and medical evidence, calculating benefit entitlements, and investigating potential fraud across all claim correspondence. Collaborating across internal teams, the role ensures claimants are kept informed, and all documentation is handled accurately within agreed timeframes.

Accountabilities

• Receive and handle enquiries and correspondence in relation to claims.
• Serve as first point of contact via email and calls.
• Validate financial and medical evidence and documentation.
• Calculate benefit entitlement based on assessed documentation.
• Identify and investigate potential fraudulent claims.
• Deal with all documentation in an accurate, professional and timely manner.
• Keep claimants informed of the progress of their claim and respond to all correspondence within agreed timeframes.

Requirements

• Related working experience required.
• Strong communication skills with a confident, polite and clear telephone manner.
• Methodical and organised with a high level of attention to detail and accuracy.
• Excellent written and verbal skills with strong time management and ability to manage own workload.
• Supportive team player.

Accurate claim entry, eligibility verification, and settlement negotiation shape the daily work of the Claims Assessor, who builds a complete record of each insurance claim from initial receipt through payment processing. Based within a structured insurance operations team and reporting through management approval workflows, the role delivers timely, validated claim resolutions that protect both policyholders and the organisation.

Functions

• Enter insurance claims received electronically or in written form.
• Answer incoming customer calls regarding claim processing.
• Document claims and associated history.
• Evaluate available information to validate claims and verify policyholder information, policy dates and premium status.
• Send claim forms to claimants for updating, correction, or completion.
• Investigate simple to moderately complex claims, determine resolution, advise claimants of status, and assist in negotiating settlement.
• Identify need for additional information and contact appropriate sources to obtain it.
• Verify beneficiary information, identify payment amounts and obtain required approvals before processing payment.

Education & Experience

• High school diploma or G.E.D.
• Fellowship of Life Health Claims (FLHC) Certification preferred.
• Two or more years of experience in auditing, accounting, contracts, or information technology.
• Experience working with insurance and medical terminology and claims processing procedures.
• Good analytical, problem-solving and data entry skills.
• Ability to maintain confidentiality of sensitive material.
• Good interpersonal communication and negotiation skills with the ability to work effectively in a team environment.

As the Claims Assessor, this role manages the Group and Retail claims portfolio across Income Protection, Total and Permanent Disablement, Trauma, Terminal Illness, and Death products, applying AFSL, LICOP, and SLA requirements to every decision. The claims team relies on this work to maintain regulatory compliance, coach assessor capability, and deliver consistent outcomes for the insured, their representatives, and Superannuation Fund Trustees.

Leadership Responsibilities

• Manage the Group and Retail claims portfolio covering Income Protection, Total and Permanent Disablement, Trauma, Terminal Illness and Death in line with AFSL, LICOP and agreed SLAs.
• Respond to requests for reviews from the insured, their representatives and Superannuation Fund Trustees on claim decisions.
• Liaise with internal and external parties including Treating Medical Practitioners, Independent Medical Examiners, Rehabilitation Providers and Underwriters.
• Provide coaching, training and mentoring to Claims Assessors to increase team capability.
• Assist in managing workflow queues, complex claims, complaints and reporting to ensure the team achieves SLAs.
• Participate in internal claims forums, projects and industry seminars to discuss complex cases and develop knowledge.

Professional Experience

• ANZIIF or ALUCA qualifications are desirable.
• Minimum 5 years of technical knowledge across Direct and Group insurance products.
• Ability to apply legislation and regulatory requirements including the Insurance Contracts Act, LICOP and RG271.
• Strong analytical, problem-solving and organisational skills with excellent attention to detail.
• Excellent relationship management skills with professional integrity and the ability to maintain confidentiality.
• Strong communication skills with the ability to meet set service standards as part of a team.

Claims Assessors in pet insurance are accountable for training assessors, overseeing claims from notification to settlement, and ensuring fraud controls and FCA regulatory requirements are met at every stage of the process. Success in the position means maintaining accurate records and databases, driving continuous improvement in internal systems, and delivering a customer experience that reflects the organisation's commitment to pet owner value.

Role Responsibilities

• Train new and existing Claims Assessors to handle pet claims from notification to settlement, validating policy cover.
• Ensure fraud controls and claims processes are followed and that all relevant documents are evaluated before claim decisions.
• Carry out checks and audits on the work of Claims Assessors to ensure a high level of accuracy at all times.
• Review pre-authorisations and re-assessments from notification to settlement in line with internal and external procedures.
• Implement company, legal and FCA regulatory policies and procedures to ensure compliance.
• Handle complaints constructively in line with FCA guidelines, escalating unusual or difficult queries appropriately.
• Identify and contribute feedback on internal processes and systems to improve customer experience and accuracy.
• Maintain accurate records, files and databases to ensure data integrity and compliance with Data Protection requirements.

Background & Experience

• Minimum 2 years of experience assessing pet insurance claims, including at least 1 year in a senior assessor role.
• At least 1 year of customer service experience.
• Experience training claims assessors and providing support and feedback.
• Good knowledge and understanding of anatomy and physiology.
• High attention to detail in documentation and record-keeping.
• Strong problem-solving and communication skills in English, verbal and written.

The Claims Assessor delivers accurate, legislatively compliant decisions on financial assistance claims made by employees owed employment entitlements following employer insolvency, preparing decision reports and conducting internal reviews under the FEG Act. Reporting through team leaders and collaborating with insolvency practitioners and claimants, the role builds a defensible evidentiary record that supports AAT and court litigation outcomes.

Day-to-Day Responsibilities

• Assess claims for financial assistance made by employees owed employment entitlements following employer insolvency.
• Work closely with insolvency practitioners managing the affairs of insolvent employers.
• Make decisions that comply with the FEG Act to ensure timely and accurate payments to claimants.
• Prepare decision reports recommending amounts payable under the claim with associated rationale and decision letters.
• Liaise with claimants and insolvency practitioners to gather outstanding information and undertake further inquiries.
• Conduct internal reviews and participate in AAT and court litigation relating to FEG claim decisions.
• Manage fraud and compliance and provide policy advice on the administration of the FEG Act.

Knowledge, Skills & Abilities

• Knowledge of administrative decision-making principles and Workplace Relations framework, including procedural fairness, or the ability to quickly acquire it.
• Proficiency in Microsoft Excel and Outlook with the ability to quickly learn program-based IT systems.
• Analytical and critical thinking skills with strong written communication and attention to detail.
• Ability to communicate complex concepts and arguments effectively to a range of audiences.
• Strong time management, organisation and interpersonal skills including collaborative working style and good judgement.
• Ability to negotiate outcomes and timeframes with internal and external stakeholders.