WC Technical Claims & Quality Assurance Manager
Mitsui Sumitomo Marine Management (U.S.A.), Inc. | Warren, New Jersey | 5/8/2017
- Responsible for all aspects of workers’ compensation technical claim audits conducted at the Home Office level to ensure full compliance with laws, regulations and internal claims handling guidelines. This includes the coordination and participation of all Claim Office audits as well as Third Party Administrators (TPAs) handling claims on our behalf.
- Provides oversight to the workers’ compensation TPAs that administer claim services for SIR/Large Deductible programs on behalf of the Insured and company to ensure full compliance with TPA Claims Service Agreements and Claims Handling Guidelines.
- Assists in the direct oversight and evaluation of Home Office Reportable claims, including internal and TPA handled claims, and makes recommendations for handling and/or resolution of claims
- Audit responsibilities: coordinates, schedules, and participates in periodic audits of Claim Offices and TPAs that handle workers’ compensation claims on our behalf. Prepare final summary reports outlining the overall claim office or TPA results for presentation to the Chief Claim Officer.
- Assist the claim offices in establishing, implementing, and monitoring Corrective Action Plans resulting from the technical audits. Conduct ongoing reviews of Corrective Action Plans for each claim office until all identified deficiencies have been eliminated. Report updates periodically to the Chief Claim Officer.
- TPA Audit – coordinate, schedule, and participate in the regular periodic audit of TPAs and MGAs that handle claims on our behalf or handle claims for our insured’s within their SIR/deductible. Complete audit report summaries and present to Chief Claim Officer. Work with TPA on any applicable Corrective Action Plan.
- Underwriting – work closely with underwriting regarding new unbundled businesses, review & evaluate proposed TPA’s, present findings/recommendations to senior management.
- Coordinate new unbundled business Claims Service Agreement discussions with Legal, Underwriting, Insured, TPA, Broker etc. to include contract drafts to final approval.
- Technology -- works with Claims Operations and IT staff to identify, manage and participate in the implementation of new technologies that offer increased efficiencies for the claims department Work with IT and other MSMM business units to establish TPA access to reporting (RRE#, EDI, Data Feeds, etc.)
- Claim Handling Manuals – works with the Claims Operations department in coordinating, maintaining, and updating MSMM Claims Handling and Procedures Manuals for the workers’ compensation line of business.
- Vendor Management – works with the Home Office Claims Operations and Compliance Department staff to enhance our vendor management for the workers’ compensation line of business including investigators, engineers, independent adjusters, bill review service providers, and other vendors utilized in the claim adjusting process. This includes negotiation of all rates and fees; service standards; contracts and vendor performance.
- Bachelor's degree preferred; High School Degree or G.E.D. is required; plus 8+ years related Workers’ Compensation Claims / Operations experience and/or training. 3+ years in a management role.
- Must have advanced WC claims technical and operational training along with demonstrated leadership ability.
- Must have the ability to travel up to 33% of the time on all forms of transportation.
JOB OVERVIEW
Pay
Industry
Category
Career Level
Competitive Salary and Comprehensive Benefits Package
Claims
Manager
Mitsui Sumitomo Marine Management (U.S.A.), Inc. (“MSMM”) is a United States subsidiary of MS & AD Insurance Group Holdings, Inc., one of the world’s top property/casualty insurance carriers with over 38,000 employees in more than 39 countries & regions worldwide.
MSMM manages the business affairs of three U.S. commercial property/casualty insurance companies: Mitsui Sumitomo Insurance Company of America, Mitsui Sumitomo Insurance USA Inc. and Aioi Nissay Dowa Insurance Company of America, all rated A+ (Superior) by A.M. Best Company (for the latest rating, access www.ambest.com).
MSMM specializes in providing commercial property and casualty insurance products and related services to customers throughout the U.S.
In joining MSMM, you are becoming part of a worldwide team dedicated to:
- Making a lasting contribution to the enrichment of society by bringing security and safety to people and businesses around the world through the sale and servicing of its insurance products;
- Realizing customer satisfaction by working to provide the finest products and services to consistently meet our clients’ growing needs; and
- Meeting our shareholders’ expectations and strengthening their trust in us by continuously improving our business.
We value each employee’s unique set of skills and contributions and believe that each employee plays an important role in the success of MSMM.
MSIG refers to the MS&AD Insurance Group insurers underwriting coverage: Mitsui Sumitomo Insurance Company of America, Mitsui Sumitomo Insurance USA Inc. and Aioi Nissay Dowa Insurance Company of America. MS&AD Insurance Group, 15 Independence Boulevard, Warren, P.O. Box 4602, New Jersey 07059-0602.
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