Offer summary

Qualifications:

Bachelor's degree required, JD preferred., Minimum of 5 years' experience in claims resolution across multiple lines of business., Strong understanding of insurance regulations, contractual obligations, and industry standards., Ability to analyze complex claim files and communicate audit findings effectively..

Key responsibilities:

Conduct audits of TPA claims handling processes to ensure compliance.

Develop and maintain audit plans, checklists, and reporting tools.

Identify performance issues, process gaps, and compliance violations, recommending corrective actions.

Coordinate with internal teams and TPA to address complex claim matters and prepare audit reports.

Job description

As the AVP of Corporate Claims you will provide Audit and oversight of TPA handling of claims in various lines of Commercial P&C business.

Key Accountabilities/Deliverables:

Conduct regular audits of TPA claims handling processes to ensure compliance with company policies, industry regulations, and contractual obligations.
Develop and maintain audit plans, checklists, and reporting tools tailored to the performance standards required by the organization.
Identify and document performance issues, process gaps, and compliance violations; recommend corrective actions and track resolution progress.
Monitor TPA adherence to service level agreements (SLAs) and claim resolution timelines.
Evaluate the accuracy and appropriateness of claim payments, reserves, and denials made by the TPA.
Collaborate with internal legal, compliance, and line of business claims teams to address complex or escalated claim matters involving the TPA.
Coordinate the preparation of audit reports and executive summaries, including data-driven insights and actionable recommendations.
Serve as the primary point of contact for communication and coordination with the TPA regarding audits, performance reviews, and corrective actions.
Provide input on contract negotiations and renewal discussions with the TPA, ensuring terms support robust oversight and accountability.
Stay current on industry best practices, regulatory changes, and emerging risks to inform ongoing TPA oversight strategy and audit methodology.

Technical Knowledge and Understanding:

Ability to analyze complex claim files and identify inconsistencies, compliance issues, or deviations from best practices across multiple lines of insurance.
Ability to communicate clearly and professionally with both internal stakeholders and external partners, including TPAs, regarding audit findings and performance expectations.
Ability to interpret and apply insurance regulations, contractual obligations, and industry standards to real-world claim scenarios.
Ability to manage multiple audits and oversight projects simultaneously, while maintaining accuracy, attention to detail, and adherence to deadlines.
Ability to think critically and strategically when identifying process improvements, assessing risk exposures, and recommending corrective actions.
Ability to maintain objectivity and confidentiality when reviewing claim files, conducting performance assessments, and handling sensitive information.
Ability to adapt quickly to changing regulatory environments, business needs, and new lines of business or systems.
Ability to use data and reporting tools effectively to monitor trends, evaluate performance metrics, and present findings in a clear and actionable format.

Experience:

College degree required
J.D. preferred
A minimum of 5 years’ experience in the resolution of claims across multiple lines of business. Preferred lines include: General Liability, Excess Liability, NYLL, Commercial Transportation, Trucking, CD, Products Liability, Hospitality, Professional Liability (D&O and E&O), and Property.

Applicants must be authorized to work for any employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa for this position.

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At Core Specialty, you will receive a competitive salary and opportunities for professional development and advancement. We offer medical, dental, vision, and life insurances; short and long-term disability; a Company-match of 100% of a 6% contribution 401(k) plan; an Employee Assistance Plan; Health Savings Account, Flexible Spending Account, Health Reimbursement Account, and a wellness program

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