TPA Claims Examiner - Workers Comp
- Career Level
- Experienced (Non-Manager)
The TPA Claim Examiner is the person accountable to HIIG for the performance of the TPA claim staff handling lower-level, non-complex worker’s compensation claims on behalf of HIIG, its policyholders and insureds; within a delegated limited authority. The role is responsible for ensuring that the segment of non-complex claims under his/her purview are managed in accordance with HIIG claim handling requirements and standards, all applicable state and regulatory requirements, and meet or exceed HIIG’s expectations in the quality of the overall claim outcomes achieved. All activities will be conducted under close supervision by the Senior Claim Director.
The TPA Claim Examiner oversees the handling of workers compensation claims which are non-complex and non-problematic that fall within the level of authority delegated to the TPA. The TPA Claim Examiner reviews reserve increases, provides guidance and input on investigation and claims management activities, and reviews claims strategically for purposes of resolution. In addition, a key element of the role is the effective management of claim related expenses by ensuring the TPA’s compliance with use of HIIG preferred claims service providers.
The TPA Claim Examiner will report directly to the Senior Claim Director – TPA WC.
To oversee and direct the claim handling activities of TPA staff as may be necessary to ensure timely and appropriate claim investigation, effective management of the claim, adherence to claim handling requirements and practices, credible assessment of exposure reflected in case reserves, and prompt and fair resolution of the claim when and where possible.
- Manages relationship with Third Party Administrator staff handling the claims within his/her purview and ensures their understanding of HIIG claim handling requirements and performance expectations
- Directs the activities of the TPA as required under close supervision by the Senior Claim Director
- Conducts continuous review and oversight of claims managed by the TPA for purposes of:
- Ensuring that claims are handled effectively, evaluated quickly
- Case reserves appropriately reflect likely outcome
- Identifying any performance issues and compliance gaps and bringing these issues to the attention of the Senior Claim Director so that necessary remedial actions can be taken
- Ensures all open claims are effectively brought to resolution at the best possible outcome at the earliest opportunity
- Identifies and evaluates additional opportunities to further reduce the severity and cost of claims
This TPA Claim Examiner role will be one in which the desired candidate will be trained to develop a depth of worker’s compensation claims ‘technical’ knowledge and experience in managing workers compensation claims subject to the regulations and requirements set forth by the Workers’ Compensation Act.
- Minimum of 2 years of experience to include direct handling of workers’ compensation claims
- Has demonstrated a proficient level of understanding of individual state workers compensation and civil laws, claims practices and regulatory requirements
- A willingness to enhance and grow their depth and understanding of workers’ compensation claims
- Strong analytical and organizational skills
- Flexibility to travel
- Utilize specialized computer software applications. Complete reports and claim histories as needed
- Demonstrate effective written and verbal communication skills
- Work independently and demonstrate good business sense
- Results oriented. A strong focus on execution and getting things done right
- A self-starter with a high level of professional maturity and a strong sense of urgency
- Thrives on and is not afraid of challenges
- Ability to establish and maintain effective working relationships with peers, staff and other functional areas.
- Ability to drive results by identifying and resolving observed problems within the scope of responsibility
Bachelor Degree Required
Licenses: Current state adjusting license is required
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