Mitsui Jobs


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

Location
Pay
Industry
Category
Career Level
Warren, New Jersey
Competitive Salary and Comprehensive Benefits Package

Claims
Manager