Claims Advisor - Credit

The Claims Advisor is responsible for the accurate and timely review, evaluation, and adjudication of credit-related claims in accordance with contractual provisions, product guidelines, company procedures, and applicable regulatory requirements. This position primarily focuses on analyzing claim documentation, validating eligibility and coverage, interpreting contract provisions, calculating benefits, and determining claim outcomes.

The Claims Advisor exercises sound judgment and attention to detail when approving, adjusting, pending, requesting additional information for, or denying claims. The role requires the ability to review financial and supporting documentation, identify discrepancies or missing information, and make accurate decisions in accordance with established guidelines and authority levels. The Claims Advisor also maintains accurate claims records, supports payment processing, and escalates complex, questionable, or potentially fraudulent claims to leadership as appropriate.

This position handles multiple credit protection products and claim types and is expected to meet established productivity, quality, accuracy, and service standards in a fast-paced production environment.

Qualifications:

- High School diploma or equivalent; associate or bachelors degree preferred.

- Minimum 2–4 years of experience in claims processing, insurance, credit protection, financial services, banking, loan servicing, healthcare administration, or a related field preferred.

- Experience reviewing contracts, policies, financial records, or supporting documentation preferred.

- Demonstrated ability to analyze information and make accurate, consistent decisions based on established guidelines

- Strong attention to detail with the ability to identify discrepancies, missing information, and inconsistencies within claim documentation.

- Strong organizational and time management skills with the ability to manage multiple claims and priorities while meeting production requirements.

- Ability to handle confidential customer, financial, and claim information with professionalism and discretion.

- Proficient computer skills, including data entry and the ability to navigate multiple systems and applications simultaneously.

- Working knowledge of claims processes, insurance terminology, credit products, loan documentation, or contract interpretation preferred.

- Knowledge of applicable regulatory requirements, compliance standards, and fraud awareness is a plus.

Primary Job Functions:

- Reviews and adjudicate credit-related claims by evaluating submitted documentation, product coverage, eligibility requirements, contractual provisions, exclusions, and applicable guidelines to determine appropriate claim outcomes.

- Analyzes loan, account, payment, employment, disability, life, or other supporting documentation, as applicable to the assigned credit product and claim type.

- Determines whether claims meet contractual and procedural requirements for payment, adjustment, pend status, additional documentation, or denial.

- Validates claim information and supporting documentation for completeness, accuracy, and consistency prior to making an adjudication decision.

- Calculates claim benefits, balances, reimbursements, or other applicable payment amounts in accordance with contractual provisions and established procedures.

- Identifies discrepancies, inconsistencies, or missing information and takes appropriate action to obtain clarification or additional documentation.

- Applies established claim authority, procedures, and escalation guidelines when making claim decisions and escalates exceptions or complex claims when appropriate.

- Maintains accurate and complete claim documentation to support claim decisions, payments, audits, regulatory reviews, and internal reporting requirements.

- Processes claim payments, adjustments, reissues, and other financial transactions accurately and within established timelines.

- Reviews claims for potential fraud, misrepresentation, or other questionable activity and escalates findings to leadership or the appropriate department for further review.

- Interprets contract language, product provisions, eligibility requirements, and applicable guidelines to ensure consistent and accurate claim determinations.

- Communicates claim decisions and documentation requirements professionally and clearly through appropriate communication channels, including email and other correspondence, as needed.

- Responds to claim-related questions from members, account representatives, lenders, internal partners, and other stakeholders when assigned.

- Updates claim systems and tracking tools accurately and timely, ensuring claim status, notes, documentation, and financial information are current.

- Maintains working knowledge of assigned credit products, claim procedures, contractual requirements, regulatory standards, and applicable compliance guidelines.

- Meets established productivity, quality, accuracy, turnaround time, and service expectations.

- Identifies recurring claim issues, process gaps, and workflow opportunities and communicates recommendations or operational challenges to leadership.

- Collaborates with Claims leadership, Operations, Compliance, Recoveries, and other internal or external partners to resolve claim issues and support effective claim administration.

- Performs other duties and responsibilities as assigned to support Claims and overall business objectives.

The above cited duties and responsibilities describe the general nature and level of work performed by people assigned to the job. They are not intended to be an exhaustive list of all the duties and responsibilities that an incumbent may be expected or asked to perform.

Skills & Competencies:

- Strong analytical and critical-thinking skills with the ability to evaluate complex information and make sound, consistent claim decisions.

- Excellent attention to detail and accuracy when reviewing claim documentation, financial information, contracts, and supporting records.

- Ability to interpret contractual provisions, product guidelines, eligibility requirements, and claim procedures.

- Strong mathematical and financial reasoning skills with the ability to accurately calculate claim benefits and payment amounts.

- Strong written and verbal communication skills are important.

- Ability to clearly document the rationale supporting claim decisions.

- Strong organizational and time-management skills with the ability to manage multiple claims and competing priorities.

- Self-starter with the ability to work independently and make decisions within established authority.

- Strong problem-solving skills with the ability to identify discrepancies, research issues, and determine appropriate next steps.

- Ability to maintain confidentiality when handling sensitive customer, financial, and claim information.

- Ability to navigate multiple systems and applications while maintaining accuracy and productivity.

- Ability to meet established quality, productivity, accuracy, and turnaround-time expectations.

- Ability to remain professional and objective when handling difficult, sensitive, or escalated claim matters.

- Strong collaboration skills and willingness to support team and operational goals.

- Knowledge of credit protection products claims processing, loan documentation, insurance, fraud awareness, compliance requirements, and regulatory standards preferred.

Additional Information:

- Full benefit package including medical, dental, life, vision, company paid short/long term disability, 401(k), tuition assistance and more.

- Fortegra is not accepting unsolicited resumes from search firms for this position.

- Internal Notice: As part of our commitment to talent development, this position is open for internal promotion applications at the time of public posting.

Job Posting Disclaimer:

Fortegra has recently been made aware of unauthorized communications regarding career opportunities by individuals not associated with Fortegra or our recruitment team. Fortegra will only contact you from the Fortegra domain address (@fortegra.com). If you receive a message from someone posing as a Fortegra recruiter via text message, WhatsApp, Telegram or other messaging platform, please report it as phishing and block the sender.

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