Annual and desk auditing of Third-Party Administrators, including preparation and presenting audit reports and findings.
Assists in the due diligence audit of potential Third-Party Administrators and the subsequent on-boarding of the TPA
Monitors oversight procedures for Third-Party Administrators
Assists in the maintenance of the guidelines for the processing of specialty accident and health insurance claims
Reviews claims exceeding Third-Party Administrator threshold, second level appeals, coordinates responses to complaints and attorneys, as well as carrier reviews and benefit clarifications
Process larger more complex claims that are not administered by Third-Party Administrators
Obtains, collates, and reviews data from monthly TPA reporting packages for trends and seeks out corrective action plan when required.
Communicate with underwriting, actuarial and product development regarding claim trends
Producing and reviewing reports for management.
Lead special projects where planning time horizon is several months or more

Prior special Accident and Health insurance claim management experience required, including substantial experience with medical claims and cost containment.
Prior experience auditing and reviewing Third-Party Administrators
Knowledge of ERISA and state claim handling requirements
Exposure evaluation and reserving skills
Bachelor’s degree or equivalent industry experience required.
Insurance designation preferred
Three to five years of A&H claim handling experience

Senior Claims Specialist

About this role