The Director of Claims Auditing and Compliance is a member of Topa’s extended executive team. The position requires the ability to communicate effectively with executives, management and other stakeholders, as well as the ability and desire to train and develop Claims staff. The Director of Claims Auditing and Compliance will have department-wide responsibility for legal and regulatory compliance, for ensuring and improving the quality of our work-product (claim files, forms and correspondence), and will be the main liaison between Claims and the Department of Insurance. The Topa Claims Department is poised for growth and we are seeking a seasoned professional who can manage change and be a leader in creating the additional regulatory and compliance framework needed to ensure the successful operations of an expanding Claims department.
Responsible for claims quality audits of Third-Party Administrators (TPA’s) and internal claims through reviews of open and closed files, providing analytical reports to management with financial and qualitative data. Ensures compliance with the Department of Insurance requirements of all states in which the company writes business and will be the primary contact for the Department of Insurance. Conducts training in accordance with DOI requirements, as well as arranging for claims technical training.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform certain duties including the following in a satisfactory manner. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Responsible for developing plans to implement claims handling procedures in states where Topa chooses to do business including researching claims requirements and ensuring compliance.
- Responsible for responding to inquiries from the various Departments of Insurance, formulating and implementing plans of action to address any issues identified.
- Responsible for the effective administration and adjustment of claims by conducting ongoing and regular claims files reviews of assigned personnel and/or audits of field operations as may be required with a diary system to monitor target files, operations or specific projects.
- Travels to TPA’s and remote operations to conduct audits and training on a regular basis.
- Reviews and analyzes financial data from TPA’s and remote operations, ensuring compliance with contractual obligations.
- Responsible for the research, planning and implementation of assigned projects and/or coordination of the projects and activities assigned to other claims management as requested by senior management.
- Understands, communicates and implements company and department policies and objectives as directed by senior claims management with accountability within the assigned areas of responsibility.
- Assists in formulating and implementing business plans and budget, claims policy, guidelines and procedures.
- Undertakes claim evaluations and extends settlement authority within delegated authority; initiates and participates in committee claim reviews.
- Objectively monitors and reports quality and productivity in assigned areas of responsibility and stimulates improvement as needed in order to meet or exceed company and departmental objectives.
- Manage talent including selection, development, training engagement and evaluation of team members and their performance.
- Ensures ongoing training of claims handling guidelines, adjusting practices and techniques, policies, rules, law, and regulations and monitors their compliance.
- Assists senior claims management in other areas as delegated.
- Adjusts and settles claims.
- Meets or exceeds company assigned objectives on a quarterly basis.
- Performs other duties as assigned.
Directly manages the internal and external claims and compliance audits and is responsible for managing the relationships with all TPA’s and remote locations. Supervises the claims operations of all TPA’s and remote locations. Carries out management responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems, and terminating employees. Must meet or exceed company and departmental objectives on a regular basis in all areas of responsibility.
The requirements listed below are representative of the knowledge, skill, and/or ability required to perform this job successfully.
- Bachelor’s degree from an accredited university preferred.
- Broad background in all phases of property & casualty claims activities obtained through actual work experience and training of at least fifteen (15) years including at least five (5) years in a supervisory or management capacity.
- Professional designations preferred.
- Keyboard speed of 45 words per minute.
- Knowledge of coverages written by the company as well as overall knowledge of the Principles of Insurance.
- Ability to effectively communicate with others verbally and in writing and listening at all levels.
- Demonstrated performance indicating a sufficient level of competence to accept job responsibilities and accountability.
- Possess analytical skills and decision-making ability to effectively recognize and evaluate coverage and claim problems.
- Proficiency in company supported claim systems, MS Word, MS Excel, Outlook and other software products preferred.
- Ability to plan, organize and establish priorities to accomplish job responsibilities.
- Physical and emotional stamina and stability to perform effectively under adverse conditions, within deadlines and with heavy workloads when necessary.
- Excellent judgement, decision making, problem-solving, analytical, planning and organizational skills.
- Possess good interpersonal skills.
- Ability to organize, motivate, train and supervise personnel to achieve company and department objectives.
- Valid Driver’s License with a clean driving record and insured automobile.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The employee is required to see, talk, and hear.
- The employee frequently is required to walk; sit; use hands to finger, handle, or feel; and reach with hands and arms.
- The employee is occasionally required to stand and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 25 pounds.
- Ability to travel (overnight stays and day trips) for business by plane or auto.
- Specific vision abilities required by this job include peripheral vision, depth perception, and the ability to adjust focus as the employee is expected to drive an automobile.