Director, Exam & Complex Claims

Marlton, New Jersey
Not Specified
Nov 21, 2020
Jan 20, 2021
Job Type
Not Specified
Career Level
Not Specified

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No Fault/SIU Examining & Quality Assurance Director will be in charge of ensuring and improving the quality claims handling for the most complex and highly sensitive cases for No Fault and SIU organizations. Under your leadership, youll be overseeing the NF/SIU examining team and NF medical nurse teams to best leverage the advanced technical expertise in the area of large loss, bad faith and coverage issues.


  • Works closely with VP and NF/SIU leadership team to define the short and long term improvement strategy for the complex claims file handling and No Fault medical case manager utilization.

  • Responsible for the development of the process, procedures, and policies for conducting Quality Assurance Reviews and Medical Case Manager Utilization for NF and SIU organizations.

  • Directs and monitors work within the unit, and advises the unit on the handling of high exposure cases. Assigns cases, special projects, and appropriate adjunct duties.

  • Oversees and conducts Quality Assurance Reviews to monitor performance of claims handling effectiveness in branch office claims handling and in the NF medical nurse services. Provides feedback to senior management regarding branch management. Ensures Action Plans are addressing applicable trends. Makes recommendations in accordance with findings.

  • Identifies gaps and variances within the operations/offices and employs root cause problem solving to understand drivers. Develops, communicates and successfully executes on plans to close gaps

  • Analyzes and evaluates high exposure claims cases for large loss, bad faith, and coverage interpretation. Advises and guides the resolution of claims. Provide recommendations to senior management in handling cases exceeding settlement authority.

  • Monitors, reviews and analyzes legal opinions to evaluate impact on policy and procedures of case handling. Updates policies and procedures as necessary and coordinates with internal and external departments (i.e., Sales, Underwriting and State Insurance Depts.), as necessary.

  • Accountable for the unit compliance with existing policies, procedures, and regulation.

  • Works with the Product, Analytics, and other examining teams to understand gaps and opportunities across the wider claims examining organization

  • Facilitates seminars, conferences, and workshops on behalf of the Claims department regarding Examining and Quality as well as Medical Nurse Service issues.

  • Leads and participates in various task forces. Serves as a company representative at various industry and trade conferences and meetings. May perform special projects as assigned.


  • Integrity, positive energy, and decisiveness are essential characteristics

  • Strong thought leadership to partner with SIU regions, NF branch offices and other examining teams to influence the strategic directions and priorities.

  • Proven records to assess strategic opportunities for field operations and drive changes in the market and sustain the improvements.

  • Ability to plan, coordinate, and organize the objectives and activities of the unit and all NF/SIU regions and brand offices.

  • Extensive knowledge of NF/SIU and overall Claims, state regulatory environments, complex injury cases and finance/actuarial/accounting practices as they apply to claims.

  • Excellent communication and management skills are required as well as the ability to deal effectively with employees at varying organizational levels and customers outside of the organization.

  • Minimum 10-15 years progressively more responsible related experience. In depth knowledge of all claims coverage's and handling procedures as well as complex medical injury claims handling.

  • Bachelor's degree or equivalent training required.

  • CPCU Designation or MBA preferred.

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