CLAIMS MANAGER JOB DESCRIPTION

Reserve adequacy and litigation outcomes in a multi-line book can deteriorate quickly when no one is watching both simultaneously. The Claims Manager holds ownership of that dual watch: overseeing the full adjudication workflow, maintaining reserve and settlement authority across general liability, auto, property damage, and workers' compensation lines, and directing third-party administrator performance against service agreements. CPCU, AIC, and ARM designations mark the technical floor of this specialty. Sound judgment on coverage interpretation and subrogation potential separates good outcomes from expensive ones.

As the Claims Manager, you drive consistent, compliant claim resolution across multi-line portfolios while managing a team of adjusters and examiners to meet production, quality, and timeliness standards set by state and federal regulatory requirements. You operate within the Claims Leadership structure, partnering with Underwriting, Risk Control, Legal, and TPA vendors to contain costs and protect the organization's reserve integrity.

Career Impact: Mastery of multi-line adjudication - spanning workers' compensation, general liability, and property damage - positions a Claims Manager as one of the most portable technical specialists in the US insurance market.

Business Impact: When reserve accuracy slips or TPA accountability goes unchecked, claim costs compound; this role directly controls both, protecting the organization's loss ratios and policyholder relationships.

Growth Opportunity: Experience setting litigation strategy, managing defense counsel panels, and achieving DWC PAR audit compliance builds the technical depth that senior claims leadership and director-level roles demand.

• Oversee daily claim adjudication across general liability, workers' compensation, and property damage lines to ensure compliance with state and federal regulatory requirements.
• Direct TPA performance against service agreements, litigation guidelines, and billing protocols to maintain cost-containment accountability.
• Establish and adjust reserve and settlement authority levels for claims examiners and supervisors within designated authority thresholds.
• Analyze claim trends, incident data, and loss run reports to identify root causes and recommend corrective action to senior leadership.
• Manage defense counsel panel relationships, including performance standards, legal bill review, and rate negotiation on litigated files.
• Coordinate investigation, liability determination, and subrogation pursuit on complex or high-value claims in partnership with outside counsel.
• Identify staff training needs and implement development plans aligned with production, quality, and claims-handling best practice standards.
• Conduct or oversee audits of claim files to verify proper handling procedures, adequate reserving, and adherence to company guidelines.

• Bachelor's degree in business, risk management, or a related field, or equivalent work experience.
• Five or more years of multi-line claims handling experience, with demonstrated progression into supervisory or management responsibility.
• Working knowledge of state and federal claims regulations, coverage analysis principles, and workers' compensation statutes applicable to assigned territories.
• Demonstrated ability to manage TPA relationships, review litigation strategy, and evaluate reserve adequacy on complex or litigated files.
• Strong analytical and interpretive skills, with the ability to identify trends across loss data and communicate findings and recommendations clearly.
• Excellent written and verbal communication skills, including experience producing management reports, coverage analyses, and staff performance documentation.
• Proven leadership capability, including experience conducting performance reviews, corrective action planning, and staff development in a claims environment.

• Professional designation such as CPCU, AIC, ARM, or CPDM actively held or in progress, reflecting commitment to technical claims mastery.
• Experience managing workers' compensation claims in a self-insured or high-deductible program environment, including familiarity with RMIS platforms.
• Prior responsibility for a defense counsel panel, including attorney performance evaluation, billing guideline enforcement, and litigation plan oversight.
• Demonstrated experience attending mediations, settlement conferences, or WCAB hearings and taking depositions on behalf of the claims department.

• Reserve accuracy rate, measuring how closely initial reserves reflect final claim settlement values across the managed portfolio.
• Claim cycle time to closure, tracking average days from first notice of loss to file closure by claim type and adjuster.
• TPA audit compliance score, reflecting adherence to service agreement standards and claims-handling best practices across assigned accounts.
• Litigation cost per file, measuring defense counsel spend relative to settlement value on litigated workers' compensation and liability claims.
• Staff quality audit pass rate, indicating the percentage of reviewed files meeting company claims-handling standards each quarter.
• Subrogation recovery ratio, tracking dollars recovered against total subrogation-eligible losses identified during the review period.
• Typical tools: Claims management systems (commonly Guidewire, Majesco); RMIS platforms (commonly Origami, Ventiv); Microsoft Office 365 (Excel, PowerPoint).

• Base Salary Range: $95,000 to $135,000 annually, depending on lines managed and team size
• Bonus: Annual performance bonus, typically 10% to 15% of base salary
• Equity: Uncommon at this level; may apply at senior manager tier in publicly traded carriers
• Health Benefits: Medical, dental, and vision coverage; employer contributions standard across the industry
• PTO: Typically 15 to 20 days annually, plus standard federal holidays
• Common Perks: Licensing and designation reimbursement (CPCU, AIC, ARM); mileage or travel allowance where field audits are required

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check and, where applicable, a motor vehicle record review consistent with the requirements of this role. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the hiring process and in the performance of job duties. Candidates must be authorized to work in the United States.

The Claims Manager owns compliance oversight and inventory control for a managed care claims operation, monitoring work queues and production standards across QC, Eligibility, UM, and Compliance departments to ensure all claims are processed within regulatory requirements. Working with management at all levels, the Claims Manager supports staff development through corrective action planning, training implementation, and daily operational reporting.

Key Responsibilities

• Ensure compliance of all claims regardless of the department where the claim is pending.
• Monitor inventory reports and assign work queues based on staffing and volume, identifying and distributing unprocessed work on a first-in, first-out basis or other established priorities.
• Work collectively with all levels of management and staff to ensure compliance with inventory production and timeliness standards across QC, T&C, Eligibility, UM, Compliance, and Operations Departments.
• Review daily operational reports throughout the day to ensure compliance.
• Maintain controls to ensure all claims are processed within regulatory requirements.
• Review daily production reports to monitor and counsel staff not meeting established production requirements.
• Review monthly report cards to train and counsel staff consistently not meeting quality standards.
• Identify training needs for staff failing to meet established minimum production and quality objectives.
• Update and implement department training materials, approved policies and procedures, and other approved reference materials required for examiner job functions.
• Hold regular unit meetings to review new policies and procedures and training issues.
• Complete Corrective Action Plans for the Claims department by requested due dates.
• Maintain in total confidence all files, documents, and records about business operations.
• Manage staff hours and attendance.
• Assess inventory versus resources and provide overtime and inventory reduction plans when necessary.

Required Qualifications

• Bachelor's degree in a related field or equivalent work experience.
• 4 or more years of experience processing managed care health claims.
• Working knowledge of managed care concepts and regulatory requirements, particularly as they relate to timeliness.
• Proficient understanding of coding concepts including ICD-9-CM, HCPCS, CPT, and ASC.
• Proficient in Microsoft Office, including word processing and spreadsheet applications.
• Strong written and verbal communication skills, with the ability to communicate clearly and concisely.
• Ability to assess work volumes versus resources and develop appropriate plans.
• Strong problem-solving skills and ability to multi-task in a demanding environment.
• Available to work extended hours and weekends as required.

Reporting to senior claims leadership, the Claims Manager shapes multi-line claims outcomes by analyzing damages, coverage, and liability on large losses while coaching staff through audit results and key performance measures across auto, liability, and fire loss lines. Working closely with Underwriting, Risk Control, and Marketing, the Claims Manager enforces productivity standards, oversees field audits, and builds a capable team through recruiting, development, and ongoing performance management.

Core Functions

• Collaborate with the Underwriting, Risk Control, and Marketing departments by providing feedback on claims trends.
• Monitor state and department results throughout the year and adjust strategy to achieve company and department goals.
• Use department key performance measures and completed audit results as tools for coaching staff.
• Recommend action by reviewing and analyzing damages, coverage, and liability issues on large losses.
• Maintain claims support quality and customer service standards, analyze and resolve difficult quality issues, initiate audits, and recommend system improvements.
• Review department-related expenses for reasonableness and necessity.
• Manage the claims support process, evaluate work results, and enforce claims support productivity standards.
• Complete administrative responsibilities including approving timecards, approving PTO, completing incentive plan quarterly reviews, and managing yearly salary administration.
• Prepare for after-hours claims emergencies by coordinating the emergency response team.
• Attend conferences and conduct field audits to provide authoritative support.
• Recruit, select, train, and develop staff while maintaining a safe, secure, and legal work environment.

Qualifications & Experience

• Bachelor's degree with 10 years of experience in multi-line claims, including direct field claims losses, coverage analysis, and litigation management.
• Recognized high-level designation such as CPCU, AIC, or CIC.
• Licensed in all states where required, with ability to obtain and maintain proper licensing before handling claims in those states.
• Significant experience in direct handling of large file investigations into auto accidents, liability claims, and fire losses, including cause and origin and subrogation.
• Prior supervisory experience overseeing Claims Representatives, Field Claims Representatives, and Auto Damage Appraisers.
• Proven record of exemplary performance in direct claims handling and supervision.
• Valid driver's license with a satisfactory driving record.

Reporting to the Head of Global PMO and functionally to the Project Manager in charge, the Claims Manager delivers structured claims oversight for major engineering, procurement, and construction projects by preparing technical, contractual, schedule, and cost back-ups for claim negotiations with construction contractors. Partnering with technical leads, the Contract Coordinator, and commercial departments, the Claims Manager drives timely claim resolution that minimizes cost and schedule impact across the project.

Primary Duties

• Support Project and Construction Managers on all questions concerning claims management and coordinate appropriate activities with technical and commercial departments.
• Propose a path forward on the subcontract and interface management strategy.
• Collect and file all contractor claims and provide weekly reports to the Project Manager, clarifying the background of claims with the responsible technical lead and Contract Coordinator.
• Prepare technical, contractual, schedule, and cost back-ups for claim negotiations with construction contractors.
• Develop strategies to reject or assess substantiated claims together with the responsible technical lead to close claims with minimum time and cost impact in line with the contract.

Education & Experience

• Master's degree in Engineering, Business Administration, Economics, or a related field, or equivalent Diploma degree.
• Several years of professional experience in handling and managing claims and disputes on major engineering, procurement, and construction projects.
• Project management experience in large EPC projects, including resource, cost, and schedule estimation and forecasting.
• Good understanding of international and interdisciplinary working environments.
• Proficient in Microsoft Excel, PowerPoint, and SAP.
• Strong interpersonal and communication skills, with the ability to convince, motivate, and lead people in office and on-site settings.
• Fluency in English required; German is an asset.
• Flexible schedule with willingness to travel and relocate as required.

Embedded within the claims operations function, the Claims Manager leads business plan development and organizational initiatives while acting in a consultative capacity on policy interpretation and settlement negotiation to resolve claims-related issues. Working closely with claims experts, vendors, service providers, and legal firms, the Claims Manager builds team capability through robust coaching and development programs that sustain both technical proficiency and service delivery.

Duties

• Participate in the development and implementation of business plans and manage operations to achieve key business goals.
• Provide effective leadership, motivate staff, and be responsible for hiring and delivering employee performance feedback.
• Provide coaching on technical and professional skills and facilitate continuous learning by building robust development plans for employees.
• Develop, recommend, and implement management and organizational initiatives to support company strategies, including changes to organizational structure and process and technology improvements.
• Act in a consultative and advisory capacity on claims matters such as policy interpretation and settlement negotiation to help resolve claims-related issues.
• Liaise with other claims experts on technical and administrative issues.
• Maintain productive business relationships with vendors, service providers, legal firms, and internal client groups.

Skills & Qualifications

• College diploma or university degree in a related field, or equivalent work experience.
• Completed or working toward a Chartered Insurance Professional (CIP) designation.
• Licensed as required by applicable provincial authorities.
• Minimum 5 years of prior work experience in claims handling.
• Knowledge of provincial legislation governing auto insurance.
• Proficiency in a variety of PC software.
• Excellent communication and interpersonal skills with all levels of staff; bilingualism is an asset.
• Experience in coaching and developing staff.
• Proven leadership skills with experience at a managerial or supervisory level.

A key member of the unit claims management team, the Claims Manager leads day-to-day coordination and supervision of claims staff by planning, organizing, and optimizing team activities using workforce analytics and available management information. Collaborating across unit managers and internal stakeholders, the Claims Manager maintains service level agreements, drives call quality standards, and takes ownership of continuous improvement initiatives that strengthen both productivity and customer service outcomes.

Functions

• Direct, coordinate, and supervise team activities by planning, organizing, and optimizing the team using workforce analytics and available management information.
• Manage team productivity and service level agreements by providing ongoing coaching and ensuring customer service and communication standards are met.
• Manage call quality of the team to ensure it meets established customer service and productivity standards.
• Participate in recruitment and hiring.
• Identify issues and take ownership to find solutions and improvements.
• Work in collaboration with other Unit Claims Managers.

Requirements

• College diploma or university degree in a related field, or equivalent work experience.
• Minimum 3 years of experience at a supervisory or managerial level.
• Experience in strategic and high-level planning and identifying areas for improvement.
• Experience in change management.
• Experience working in a contact centre environment with exposure to contact centre systems is preferred.
• Experience in insurance is considered an asset.
• Leadership skills including the ability to motivate and coach staff to deliver results.
• Excellent communication and interpersonal skills with all levels of staff; bilingualism is considered an asset.
• Strong organizational, analytical, and time management skills.
• Ability to analyze and interpret team results.

The Claims Manager produces fully substantiated claims and manages the complete incoming and outgoing claims process for a global technology company operating across airports and postal and parcel service providers in more than 60 countries. Collaborating with project management, procurement, and legal counsel, the Claims Manager develops risk and opportunity strategies, ensures contractual documentation integrity, and represents the organization in negotiations, mediation, arbitration, and court proceedings.

Technical Responsibilities

• Analyze contracts by identifying formal requirements, claim potential, and risks and opportunities.
• Contribute to contract workshops and the development and implementation of strategies for risk and opportunity management, regularly reviewing claim strategy with project management.
• Identify, evaluate, and ensure proper follow-up on all events relevant to incoming and outgoing claims.
• Collect, prepare, and manage relevant documents, including drafting of letters and evidence, in accordance with contractual deadlines and requirements.
• Ensure structured documentation of contract deviations, amendments, and changes.
• Support project management and procurement teams proactively on contract-related matters for main contracts, consortium contracts, and subcontracts to ensure rights are safeguarded and risks are mitigated.
• Prepare and produce fully detailed and substantiated claims, including extension of time and associated costs, and safeguard the organization from incoming claims.
• Participate in claim-related negotiations and disputes, including mediation, conciliation, arbitration, and court proceedings.
• Collaborate with functional departments and align with legal counsel on legal matters.

Position Requirements

• Law degree, or a technical or commercial degree from an accredited institution.
• At least 5 to 10 years of experience in contract-related activities.
• Experience in international project business, preferably with a multinational company and internationally staffed teams, including preparation and negotiation of terms and conditions across contract types.
• Knowledge of sales, projects, and commercial issues in infrastructure project business is an asset.
• Knowledge of scheduling systems and techniques for substantiation of Extension of Time claims is beneficial.
• Strong negotiation, analytical, and problem-solving skills.
• Ability to think through situations from a conceptual perspective.

Consistent resolution of general liability, property damage, and workers' compensation claims across the US depends on the Claims Manager, who controls investigation, reserving, settlement negotiation, and litigation management both in-house and through a third-party administrator. Based within the Risk Management department, the Claims Manager serves as the internal subject-matter expert on third-party contracts and risk transfer, pursuing subrogation opportunities and leading the organization's crisis response on catastrophic events.

Accountabilities

• Manage general liability, property damage, and workers' compensation claims either in-house or through a third-party administrator.
• Direct immediate and thorough response to incidents by coordinating with on-site teams, injured employees, Safety, Procurement, Engineering, HR, Benefits, Legal, and outside vendors.
• Serve as an in-house subject-matter expert for all claim matters regarding third-party contracts, including downstream and contractor agreements, to effectuate successful risk transfer.
• Control investigation, liability determination, reserving, settlement negotiation, and litigation management, and settle claims within designated authority.
• Direct the third-party administrator and outside counsel in handling pleadings, discovery, and strategy, ensuring cost-containment and accountability to service agreements.
• Attend and participate in mediations, settlement conferences, and trials.
• Identify and pursue subrogation opportunities.
• Create and implement protocols and processes and select new vendors to mitigate claim severity and costs.
• Maintain the risk management information system and manage vendor relationships.
• Oversee catastrophic claims or events and serve on the crisis response team.

Experience & Qualifications

• 5 or more years of complex claims experience in general liability, property damage, and workers' compensation, including investigation, liability determination, reserving, settlement negotiation, and litigation management.
• Licensed All-Lines Adjuster in at least one state preferred.
• Insurance designations such as ARM, AIC, CPDM, or CPCU preferred.
• Thorough knowledge of claim procedures, state and federal laws, and insurance regulations.
• Strong written and verbal communication skills.

As the Operations Claims Manager, this role oversees management and administration of multiple functions within the Disability Claims Department, owning both financial and non-financial accountability for day-to-day site operations across one or more business units. The department relies on this work to authorize claim payments, achieve performance guarantees, and sustain productive partnerships with clients, vendors, and internal cross-functional teams.

Operational Focus

• Oversee daily operations of multiple levels of staff and multiple functions across one or more business units.
• Manage day-to-day site operations with accountability for financial and non-financial results, including budgets and actuals.
• Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing, and adjusting claims.
• Attend and participate in customer meetings to discuss feedback and needed process enhancements.
• Initiate and maintain partnerships throughout the organization by promoting common goals, building trust, and supporting cross-functional activities.
• Authorize appropriate payments or refer claims to investigators for further review.
• Analyze and identify trends and provide reports as necessary.
• Lead project management and implementation initiatives.
• Support employee development by conducting regularly scheduled one-on-ones with direct reports.
• Provide oversight to ensure the team successfully achieves targets to meet performance guarantees.

Background & Experience

• Bachelor's degree required.
• Claims industry experience.
• 5 or more years of supervisory, managerial, or leadership experience in claims adjudication or customer service.
• Experience managing relationships with clients and vendors.
• Experience managing budgets, process improvement, and quality assurance.
• Proficient in Microsoft Excel, including pivot tables, basic formulas, sorting, and data interpretation.

Claims Manager builds a high-performing adjusting team by supervising both staff and independent adjusters, assigning claims based on workload and experience while advising on coverage, liability, and claim strategy across a broad book of business. The work directly supports compliance with state and federal requirements, timely reserve establishment, and proactive communication with other departments on risk evaluation and claim trends.

Leadership Responsibilities

• Supervise team and independent adjusters in the performance of their functions.
• Assign claims to the appropriate adjuster based on workload, claim volume, type of claim, and adjuster experience.
• Advise staff on questions of coverage, liability, claim value, and strategy.
• Examine claim files to determine whether proper claim handling procedures are being followed.
• Ensure timely and adequate reserves have been established.
• Communicate with other departments regarding risk evaluation, account activity, significant reserve changes, and claim trends.
• Review litigated files.
• Oversee compliance with state and federal requirements.

Professional Experience

• Bachelor's degree or equivalent relevant work experience.
• Insurance designations preferred.
• 10 years of claims handling experience in progressively responsible roles, including supervisory functions.
• Proven knowledge of insurance contracts, medical terminology, and legal aspects of court procedures.
• Superior knowledge of the claim function, including analytical ability and excellent judgment regarding liability and coverage.
• Excellent leadership qualities and superior investigative and problem-solving abilities.
• Proficient in computers and claims systems.
• Valid driver's license with an acceptable motor vehicle report required if traveling.

The Claims Manager owns the design, execution, and audit of service claims policies and procedures for a warranty service network, working closely with the management team to maintain desired loss cost ratios across all business units. Operating across claims adjudication, reserve analysis, electronic claims processing, and actuarial evaluation, the Claims Manager ensures payment cycle compliance and delivers monthly performance reports to internal and external stakeholders.

Role Responsibilities

• Design, implement, and execute various policies and procedures for service claims.
• Implement all business requirements and ensure optimal handling of all claims.
• Evaluate all new claims, administer data integrity, and manage communication to established claims rules.
• Provide training to team members related to claims adjudication processes and procedures and design an efficient program to manage claims.
• Perform regular quarterly audits on all service account claims.
• Monitor effectiveness of all programs, support open claim file reviews, and manage all payment cycles to ensure compliance with contract requirements.
• Design and maintain a panel of audited claims and prepare reports for monthly review across all business units.
• Analyze all claims to ensure optimal quality, prepare reports for business units, and monitor all expenses.
• Perform investigations on all reserve increases and conduct regular surveillance of all claim issues.
• Schedule internal and external audits on all claims issues and supervise the processing of all billing issues.
• Oversee all electronic claims processes, prepare claims reports, and evaluate actuarial data.

Qualifications & Experience

• Bachelor's degree in a related field or equivalent experience.
• Strong organizational, problem-solving, and analytical skills, with the ability to manage priorities and workflow.
• Ability to handle multiple projects simultaneously and meet deadlines.
• Good judgment with the ability to make timely and sound decisions.
• Strong interpersonal skills, with the ability to deal effectively with individuals at all organizational levels.
• Excellent written, oral, and presentation communication skills.
• Ability to work independently and as a member of various teams and committees.
• Adaptable and flexible, with a willingness to work within constantly changing priorities.

Sitting at the intersection of technical claims oversight and operational management, the Claims Manager leads Professional Liability operations across multiple assigned offices with up to 74 full-time colleagues, managing staffing, training, budget preparation, and profit and loss accountability. Operating across client service coordination, quality programs, and compliance with state regulations, the Claims Manager establishes business plans and performance development structures that sustain consistent service delivery.

Strategic Responsibilities

• Oversee overall Professional Liability operations management for assigned locations.
• Establish policies and procedures to assure compliance with best practices, claims management services standards, state regulations, and client service requirements.
• Establish a business plan with goals and objectives for assigned locations.
• Monitor management reports relating to office performance.
• Assist with the coordination of sales and client service efforts.
• Support the organization's quality programs.
• Administer personnel policies and follow staffing standards and training recommendations.
• Interview, hire, and establish colleague performance development plans, and conduct colleague performance discussions.
• Provide support, guidance, leadership, and motivation to promote maximum performance.

Education & Experience

• Bachelor's degree from an accredited college or university preferred.
• CPCU, ARM, AIM, or AIC certifications preferred.
• Licensed as required by applicable authorities.
• 8 years of Professional Liability experience, or equivalent combination of education and experience, including 3 years of prior supervisory experience.
• Strong technical claims knowledge and excellent negotiation skills.
• Proficient in Microsoft Office products.
• Excellent oral and written communication skills, including presentation skills.
• Strong leadership, analytical, interpretive, and organizational skills.
• Ability to travel as required.

As the Claims Manager, this role advances accuracy and coordination of claims set-up with TPA offices, ensuring all claims are processed in accordance with CMS guidelines while conducting audits, root cause analyses, and post-payment coding reviews to maintain compliance with contract requirements. Partnering with finance leadership, health services, and network contracting teams, the Claims Manager resolves complex payment issues and develops trend reports that guide committee-level improvement initiatives.

Day-to-Day Responsibilities

• Ensure the plan meets standards for claims adjudication.
• Identify risks and ensure processing of all claims per CMS guidelines.
• Analyze claims to ensure optimal quality and coordinate with finance leadership for check run approvals.
• Review and analyze provider disputes.
• Perform root cause analysis of claims payment discrepancies.
• Conduct post-payment coding reviews.
• Complete audits on accuracy of claims system set-up and manage payment cycles to ensure compliance with contract requirements.
• Participate in workgroups to resolve complex payment issues involving claims configuration, health services, network, and contracting.
• Analyze complaint, appeal, dispute, and grievance data, develop trend reports, and work with committees to identify opportunities for improvement.
• Oversee the investigation and resolution of provider claim disputes and appeals.

Knowledge, Skills & Abilities

• Ability to interpret coding guidelines, CMS regulations, Medicare reimbursement, and Medicare Claim Processing for accurate application of policy to claim edits and audits.
• Proficient in Microsoft Word, Excel, PowerPoint, and Outlook, including internet and intranet navigation.
• Strong analytical and problem-solving skills with strong attention to detail and accuracy.
• Excellent organizational skills with the ability to prioritize and simultaneously maintain multiple projects at a high level of quality.
• Ability to communicate effectively at all levels of the organization and work well within a team environment.
• Ability to work with minimal supervision, take initiative, and make independent decisions.
• Adaptable and approachable, with flexibility and personal integrity.
• Customer service-oriented with the ability to work well under pressure.

Reporting to senior risk management leadership, the Claims Manager refines workers' compensation and general liability claims outcomes by investigating, evaluating, and settling claims while managing TPA relationships, defense counsel, reserve-setting, and subrogation pursuit across a multi-line carrier or TPA environment. Partnering with Finance and HR, the Claims Manager executes supervisory duties, delivers weekly and monthly loss trend reports, and educates field managers on risk management policies and procedures.

Ownership Areas

• Investigate, evaluate, strategize, negotiate, and settle all workers' compensation claims.
• Analyze incident data to determine root causes and estimated costs of employee injuries, vehicle accidents, and general liability losses.
• Respond to coverage inquiries.
• Interact with third-party administrators and defense counsel to manage claims, litigated files, set reserves, and settle files within authority.
• Pursue subrogation on behalf of the organization and its affiliated companies.
• Educate field managers on risk management policies and procedures.
• Provide weekly and monthly claims reports.
• Analyze loss trends and root causes of insurance losses.
• Coordinate with the Finance department on claims-associated costs.
• Carry out supervisory duties, including planning, assigning, and directing work, interviewing, hiring, training, evaluating performance, and partnering with HR to resolve escalated employee matters.

Education & Experience

• Bachelor's degree in a relevant field, with ARM or AIC designation preferred.
• 5 years of multi-line claims experience in a carrier or third-party administrator environment.
• 5 years of management experience.
• Extensive knowledge of applicable workers' compensation laws, procedures, and regulations.
• Extensive knowledge of medical and technical terminology used in workers' compensation cases.
• Proficient in Microsoft Office.
• Highly organized, detail-oriented, and able to maintain a high level of confidentiality.
• Excellent verbal and written communication skills with strong analytical and problem-solving skills.
• Ability to multi-task and work under tight deadlines.
• Valid driver's license with a driving record meeting company requirements, and ability to travel up to 10% of the time.

The Claims Manager oversees client engagements focused on Operational Risk, Regulatory Compliance, Conduct Risk, and Third-Party Risk Assessments for capital markets organizations, including asset management firms, broker dealers, and wealth management firms, delivering recommendations to client senior leadership while guiding team deliverables. Working closely with engagement leads, regulatory bodies such as the SEC, FINRA, CFTC, and NFA, and internal recruiting and business development teams, the Claims Manager advances go-to-market efforts and builds the practice through proposal preparation and executive relationship development.

Scope of Work

• Develop frameworks and methodologies for operational and regulatory risk-management programs.
• Review client processes and controls against leading practice and industry frameworks, identify gaps in design and execution, and communicate issues and recommendations to engagement leads and client management.
• Plan and execute client engagements focusing on Operational Risk, Operational Resilience, Regulatory Compliance, Surveillance, Conduct Risk, and Third-Party Risk Assessments.
• Lead go-to-market and business development efforts, including preparation of proposals for prospective clients and client presentations.
• Contribute to project management and administration, including contracting, budget management, and managing day-to-day client relationships.
• Lead and deliver engagements for capital markets organizations by guiding and overseeing the quality of team deliverables and providing recommendations to client senior leadership.
• Provide leadership and oversight to team members regarding deliverables, project plans, and performance.
• Lead recruiting and retention efforts to develop the practice.

Minimum Qualifications

• Bachelor's degree from an accredited college or university, or equivalent work experience.
• Minimum 5 years of experience in a regulatory compliance or risk management function within a capital markets organization, regulatory agency, or consulting firm.
• Minimum 2 years of experience with SEC, FINRA, CFTC, NFA, or other capital markets regulators, with direct work at one of these bodies strongly preferred.
• Experience in leading and executing large or complex projects with multi-disciplinary teams.
• Strong leadership and communication skills with the ability to write at a publication-quality level.

Claims Manager guides contractual and commercial claim resolution on mega infrastructure projects, including major earthworks, rail systems, and civil programs, performing delay analysis, quantum evaluation, and audit of contractor applications within customer organizations. The commercial team relies on this work to ensure exposure is correctly diagnosed, accurately reported, and effectively mitigated through robust strategies for counterclaims, defenses, and dispute proceedings, including FIDIC-governed arbitration.

Project Responsibilities

• Provide analysis and evaluation of claims.
• Evaluate both contractual and legal entitlement.
• Identify, collect, and evaluate relevant facts and records.
• Collate related information and provide analysis based on facts, records, and contract requirements.
• Prepare, perform, brief, and advise strategies for claim resolution, defenses, and counterclaims.
• Prepare reports, presentations, and recommendations related to claims and disputes.
• Interface with the delay analysis process for all planning and time elements of claims.
• Advise and perform appropriate methods of delay and program analysis, including evaluation of quantum.
• Produce well-written, concise reports and letters with minimal revisions required.
• Manage the input of the commercial view into the customer's decision-making process around triggering disputes or litigation.
• Undertake audits of contractor applications, certifications, variations, and claims.
• Collaborate with the Commercial Director, Senior Contracts Managers, Contracts Administrators, and the customer's commercial team to ensure exposure is correctly diagnosed, accurately reported, and effectively mitigated.

Technical Qualifications

• Degree in business, construction, law, or a related discipline.
• Minimum 20 years of experience in contracts, including claims and dispute administration or commercial management, with a minimum of 10 years managing claims and disputes on major infrastructure projects.
• Minimum 5 years of experience managing teams.
• Extensive experience on mega infrastructure projects, including major earthworks, rail systems, and civil programs within customer organizations.
• Extensive experience working with FIDIC and bespoke contracts.
• Fluency in reading, writing, and spoken English.

A key member of the risk management function, the Claims Manager coordinates the overall claims process for self-insured GL, AL, and PD claims, overseeing third-party administrator performance, collaborating with in-house and outside legal counsel on defense strategy, and organizing monthly loss run and litigated file reviews with management. Collaborating across operations, legal, and TPA partners, the Claims Manager sustains accountability to client service instructions and billing guidelines while coaching claim examiners on handling best practices.

Key Deliverables

• Conduct and oversee claim investigations and resolution of self-insured claims.
• Coordinate the overall claims process including investigation and discovery, litigation management, and settlement authority.
• Collaborate with in-house and outside legal counsel to assure proper handling of litigated files, including gathering pertinent legal information and claims documentation, managing deposition requests, identifying and preparing witnesses, and developing overall defense strategy.
• Provide oversight and management of third-party administrators on GL, AL, and PD claims, including claim handling best practices, adherence to client service instructions, litigation guidelines, and billing guidelines.
• Manage claim reviews in partnership with the third-party claims administrator to ensure claim handling is aligned with expectations.
• Provide coaching and direction to claim examiners as needed.
• Attend mediations and other settlement conferences as necessary.
• Organize and facilitate monthly loss run reports, litigated file reports, and claim review meetings with management.
• Guide operations on handling incidents as they may arise.
• Tender and track progression of other types of claims as necessary.

Required Qualifications

• Minimum 8 years of experience in a corporate risk management department or large insurance carrier liability claims operation.
• Strong foundation in claims adjustment, TPA management, and litigation management.
• Knowledge of risk management information systems, database analytics, claims trends, reserve setting, and analysis.
• Proficient in Microsoft Office 365, including Excel and PowerPoint.
• Excellent written and verbal communication and organizational skills.
• A collaborative approach to problem-solving.
• Ability to work autonomously with a high level of attention to detail, manage multiple projects efficiently, and provide exceptional service to internal and external clients.

The Claims Manager creates the analytics framework and defense panel infrastructure that shortens claim cycle time and reduces litigation costs across all workers' compensation litigated files, reporting to the Vice President of Claims and consulting with claims leadership on litigation referrals, legal hearing strategy, and DWC PAR Audit compliance. The work directly supports the Claims Leadership Team's goal of consistent, good-faith claim resolution in compliance with WCAB statutes and California regulations.

Executive Functions

• Manage all litigated files in the Claims Department.
• Analyze, consult, and direct on litigation plans as appropriate.
• Maintain compliance with DWC PAR Audit standards and internal claims handling guidelines.
• Manage defense counsel billing rates, reimbursable items, and review legal bills for compliance with litigation guidelines.
• Document the claim file of all activities taken.
• Develop analytics to identify trends, savings opportunities, and strategies to shorten claim cycle time to resolution and closure.
• Manage litigation throughout the life of the claim in collaboration with the assigned examiner.
• Assign and supervise defense attorneys when appropriate.
• Apply cost containment techniques including strategic vendor partnerships to reduce overall cost of claims.
• Develop and maintain a defense attorney panel with emphasis on quality and consistency.
• Maintain professional vendor relationships.
• Execute claims activities consistently to ensure delivery of quality claims service.
• Manage shared responsibilities for the department budget.

Skills & Qualifications

• Bachelor's degree from an accredited college or university preferred.
• 5 or more years of successful claim management or leadership experience.
• In-depth knowledge of workers' compensation laws and legal principles applicable to claims handling.
• Experience in attending WCAB hearings and taking depositions.
• Strong written and verbal communication and negotiation skills.
• Strong analytical skills.
• Ability to mentor and motivate staff.

Embedded within a healthcare liability claims function, the Claims Manager oversees non-asserted claims reported to the carrier and manages professional liability claim trends through medical review, internal expert oversight, and collaboration with legal, quality, credentialing, and provider enrollment departments. Working closely with defense counsel, carrier representatives, and the Director of Claims, the Claims Manager sustains exposure reduction strategies and supports yearly audits that protect the organization's risk posture.

Work Activities

• Determine potentially compensable events.
• Analyze, evaluate, and communicate patterns and trends of professional liability claims.
• Assist in coordinating bi-monthly claims management meetings.
• Make recommendations concerning exposure reduction.
• Assume coverage of claims management activities in the absence of the Director of Claims.
• Assist with yearly audits.
• Work closely with the legal, quality, credentialing, and provider enrollment departments.
• Contribute to company risk management efforts as directed.
• Participate in committee and carrier meetings as needed.
• Compose, prepare, maintain, and distribute word processing documents, spreadsheets, databases, graphs, presentations, reports, and other department documents with an emphasis on accuracy.
• Gather pertinent data from a wide variety of sources using specialized software applications.
• Create and maintain manuals, records, and electronic and hard copy files.

Professional Experience

• Broad knowledge of legal principles and processes specific to professional liability litigation.
• Working knowledge of the discovery process and risk management guidelines.
• 3 or more years of experience working for a law firm or liability insurer.
• Experience in medical-legal chart review.
• Knowledge of claims management processes.
• Nursing experience in utilization review, case management, or legal nurse consulting is helpful.
• Proficient in computer skills with the ability to learn a claims management system.
• Excellent oral and written communication skills.
• Excellent organizational and problem-solving skills with strong attention to detail.
• Ability to work autonomously, multi-task, and manage daily workflow to ensure timely reporting and follow-up.

Claims Manager runs a full-scope workers' compensation claims operation, establishing and communicating settlement and reserving authorities, managing annual expense budgets, and directing staff development to deliver compliant, high-quality outcomes across self-insured and standard programs. Success in the position means monitoring legislative changes across service territories, participating in high-value claim conferences, and collaborating with Underwriting, Risk Control, and Marketing to sustain superior customer service and defensible claim results.

Strategic Responsibilities

• Develop and implement short- and long-range objectives consistent with company business goals, guidelines, and programs.
• Ensure quality management of claims in accordance with best practices and company guidelines.
• Maintain appropriate staffing levels in conjunction with workloads.
• Select, train, and manage staff.
• Plan staff responsibilities and manage activities, utilizing staff resources effectively to meet department goals in accordance with approved plans and budgets.
• Develop staff to respond to department needs and assist claims staff with career development goals.
• Plan and develop the annual expense budget for areas of direct responsibility.
• Identify training needs for staff and establish and implement a strategy to deliver training.
• Establish and communicate claims settlement and reserving authorities for claims professionals.
• Grant reserve and settlement authority on cases exceeding supervisor's authority levels.
• Monitor and analyze significant legal developments and legislative changes in service territories that may affect claim operations.
• Participate in claim conferences to establish strategy, reserves, and settlement authority on the most complex or highest-value claims.
• Collaborate with Underwriting, Risk Control, Product Development, Marketing, and other departments.
• Manage the account management process and resolution of service issues.
• Participate in the defense counsel evaluation process and make recommendations for addition or removal of counsel.

Experience & Qualifications

• Bachelor's degree or equivalent experience.
• Professional designations such as CPCU, ARM, or AIC are desired.
• 10 or more years of workers' compensation claims experience in positions of increasing responsibility.
• 2 years of claims management experience.
• Experience handling claims in Texas, with TX License and applicable state certificate required.
• Prior experience handling or managing claims for self-insured entities.
• Extensive knowledge of claims regulations, applicable law, self-insured programs, adjusting techniques, and medical terminology.
• Proven record of successful team building, goal achievement, and superior customer service in a leadership role.
• Ability to effectively lead supervisory-level staff.
• Excellent verbal and written communication skills.