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.