Claims SME

Who are we Fulcrum Digital is an agile and next-generation digital accelerating company providing digital transformation and technology services right from ideation to implementation. These services have applicability across a variety of industries, including banking & financial services, insurance, retail, higher education, food, healthcare, and manufacturing.

Job Title: Sr. Claims Analyst / Subject Matter Expert (SME) Domain: Property & Casualty (P&C) Insurance Reports To: Claims Team Lead / Operations Manager ───────────────────────────────────────────── ROLE OVERVIEW ───────────────────────────────────────────── 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. ───────────────────────────────────────────── EXPERIENCE REQUIRED ─────────────────────────────────────────────

• 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. ───────────────────────────────────────────── KEY RESPONSIBILITIES ───────────────────────────────────────────── 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. ───────────────────────────────────────────── SKILLS REQUIRED ───────────────────────────────────────────── 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. ───────────────────────────────────────────── KEY PERFORMANCE INDICATORS (KPIs) ─────────────────────────────────────────────
• 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.