WHAT DOES A CLAIMS MANAGER DO?

The Claims Manager oversees the execution of audit and action plans to meet performance standards and directs the development and evaluation of claims and managed care programs to improve outcomes and reduce costs. This role also ensures compliance with federal, state, and local regulations, maintaining high service delivery standards across all operations. Additionally, the Claims Manager drives continuous improvements and financial efficiencies within the department.

A Review of Professional Skills and Functions for Claims Manager

1. Claims Manager Duties

  • Claims Management: Ensuring that claim filing systems and claim registers are established and maintained.
  • Documentation Accuracy: Ensuring that contemporaneous records are correctly maintained and that contractual claim-related notifications and correspondence are issued correctly and on time.
  • Risk Management: Supporting Project Managers (Commercial) in claim-related risk and opportunity identification, quantification, and mitigation.
  • Stakeholder Engagement: Ensuring that regular Project and commercial meetings with the customer, partners, and vendors are held to review the progress of claims and to settle claims.
  • Contract Negotiation: Drafting and negotiating settlement agreements/change orders accordingly.
  • Training Delivery: Providing guidance, support, and training to Project teams on claims management.
  • Legal Collaboration: Collaborating with and supporting the legal team in the event of actual or potential arbitral or litigation proceedings related to claims.
  • Leadership: Helping the continued development of the Contract Management discipline by leading and participating in broader initiatives across the function.
  • Investigation Oversight: Ensuring appropriate claim investigations according to company policies and procedures.
  • Staff Management: Managing staff (including employee retention and professional development), workflow, subrogation.
  • Complaint Resolution: Reviewing and responding to consumer, attorney, regulatory, and BBB complaints.

2. Claims Manager Details

  • Process Optimization: Continuous improvement of SOPs and KPIs.
  • Compliance Management: Ensuring appropriate claim investigations according to company policies and procedures.
  • Staff Management: Managing staff (including employee retention and professional development), workflow, subrogation.
  • Strategy Development: Assisting in the development and maintenance of departmental staffing strategy.
  • Communication Skills: Excellent business writing skills-writing sample will be required as part of the application.
  • Relationship Building: Forging strong working relationships with internal and external business leaders.
  • Adaptability: Managing competing demands while being extremely adaptable and flexible.
  • Stakeholder Engagement: Liaising with internal and external stakeholders to ensure timely and quality management of claims.
  • Project Participation: Participating in business areas and/or company projects.
  • Technical Support: Providing continuous support to the tech team.
  • Client Relations: Building, managing, and maintaining good working relationships with clients and partners.
  • Insurance Collaboration: Working closely with insurance partners for claim settlement handling.
  • Strategy Implementation: Developing and implementing business strategies to provide accurate and proactive customer service to members, plan sponsors, and brokers aligned to the service center.

3. Claims Manager Responsibilities

  • SLA Compliance: Ensure all claim functions and processes abide by agreed SLA frameworks.
  • Process Improvement: Perform a continuous improvement process to the claims process.
  • Documentation Management: Prepare and revise Guidelines / SOP / Working Instructions related to claim functions.
  • Reporting: Generate claims reports on department-wide activities and progress as required.
  • Department Oversight: Oversee the claims department, ensuring the quality of the claims process and the outcomes.
  • Quality Assurance: Undertake quality assurance review of claims files.
  • Technical Advice: Provide advice on the technical interpretation of policies and contract requirements.
  • Customer Resolution: Accountability for the resolution of customers’ complaints or requests for decision reviews (within authority).
  • Stakeholder Communication: Provide inputs in clients’ and partners’ communication relating to the management of their claim(s) and attending to their inquiries.
  • Customer Correspondence: Draft correspondence to customers including requests for additional information, coverage letters, and rejection of claim notices.
  • Claim Analysis: Review and analyze claim documentation.
  • Claim Adjustment: Adjust and settle first-party property damage claims.
  • Compliance Assurance: Ensure compliance outcomes are included in all plans and goals.

4. Claims Manager Job Summary

  • Customer Correspondence: Draft correspondence to customers including requests for additional information, coverage letters, and rejection of claim notices.
  • Claim Analysis: Review and analyze claim documentation.
  • Claim Adjustment: Adjust and settle first-party property damage claims.
  • Policy Review: Review and analyze policy documents.
  • Customer Interface: Act as the first point of contact on various claim calls and inquiries.
  • Vendor Management: Assign and work with independent adjusters, and review and pay bills from outside vendors.
  • File Management: Maintain electronic claim files, identify and maximize claim settlement opportunities.
  • Stakeholder Liaison: Liaise directly daily with insureds and brokers.
  • Coverage Correspondence: Issue substantive coverage correspondence to clients and brokers.
  • Task Flexibility: Perform additional tasks as assigned by the Director of Insurance & Claims.
  • Operational Support: Provide operational support for market management of plan sponsors, members, and network providers.
  • Service Monitoring: Monitor and evaluate service center operational plans ensuring customer service standards are maintained during facility shutdowns (anticipated or unanticipated) and during business activity transfers between locations.

5. Claims Manager Accountabilities

  • Operations Management: Oversees the operations of multiple service centers in different locations handling a Claims Operation function.
  • Systems Oversight: Utilizes expert knowledge to oversee operating systems including policies and procedures, operating structure, and information flow across multiple service centers.
  • Service Standards Direction: Directs implementation of Claims service standards for each location to ensure delivery of quality-focused, consistent cost-effective service and administration both in-house and for work administered by vendors.
  • Operational Analysis: Analyzes claims operational practices for effectiveness and practicality, while creating a culture which is innovative in its approach to solutions.
  • Vision Setting: Establishes a clear vision aligned with company values, sets specific challenging and achievable objectives and action plans.
  • Team Motivation: Motivates others to balance customer needs, budgets, and business success.
  • Talent Development: Develops an organization that attracts, selects, and retains high caliber, diverse talent able to successfully achieve or exceed business goals.
  • Team Building: Builds a cohesive team that works well together and across other business segment functions.
  • Budget Management: Effectively and proactively manages to budget, analyzing and acting upon financial variances from plan by identifying additional cost-saving strategies.
  • Billing Validation: Validates production billing volumes and rates across the global platform.
  • Leadership: Leads and builds high-performance teams across units by providing leadership, mentoring, and coaching in achieving understanding of the voice of the customer.
  • Leadership Accountability: Accountable for leading staff in accordance with Aetna’s standards of leadership excellence.
  • Plan Coordination: Coordinates major plan modifications necessitated by unanticipated business or technology developments.

6. Claims Manager Functions

  • Team Development: Work with Managers and develop staff to provide and maintain a productive, efficient, and effective claims department to pass health plan audits.
  • Quality Improvement: Improve the quality, such as payment accuracy and timeliness.
  • Standard Revision: Review and revise productivity and quality standards.
  • Resource Monitoring: Monitor inventory or other reports daily to ensure adequate resources are applied to maintain departmental goals of timeliness and quality.
  • Training Coordination: Determine areas within the department requiring concentrated training efforts and plan appropriate actions to address training needs.
  • Regulatory Compliance: Oversee department activities to ensure health plan and regulatory compliance are maintained.
  • Policy Development: Develop and modify policies and procedures.
  • Cross-functional Collaboration: Participate with other departments and cross-functional work groups on issues related to departmental and organizational efficiencies.
  • Staff Support: Provide support to staff in efforts to maximize efficiencies of staff.
  • Automation Development: Assist in the development of automated solutions to prevent adjudication errors.
  • Goal Setting: Develop departmental and individual goals.
  • System Improvement: Identifies system issues, upon their resolution, additional automation and accuracy is achieved.
  • Resource Provisioning: Assure staff has the information and tools necessary to perform their functions.

7. Claims Manager Job Description

  • Leadership: Heads all insurance E2E-based business GCC and ensures account management for GCS business E2E.
  • Claims Oversight: Oversees the overall claims teams and processes including back-office claims.
  • Policy Implementation: Drives and enforces development and local implementation of foundational and strategic group claims policies, standards, and processes for claims handling.
  • Compliance Enforcement: Enforces group claims guidelines and compliance.
  • Performance Management: Accounts for the overall performance of the Claims Department through designing, enforcing, and tracking KPI Reporting and Analysis with a strong focus on excellent customer experience.
  • Team Development: Develops/maintains a high-performing team with a focus on increasing claims management and insurance knowledge and expertise, but also an optimal mix of technical/operational/leadership capabilities to deliver on business objectives.
  • Culture Building: Creates and maintains a culture of risk awareness and fraud awareness, prevention, and control.
  • Standards Setting: Sets local standards across all claims teams, including competence, quality assurance, fraud, and risk management together with respective functions.
  • Digital Transformation: Supports/Drives digitalization and automation of the Claims Target Operating Model.
  • Quality Improvement: Drives and enforces quality and performance improvements (analysis of processes, team structure, products).
  • Business Growth Support: Supports the GCC business growth by actively participating in all pre and onboarding processes with potential and new clients as claims, risk, and fraud expert.
  • Risk Management: Manages within underwriting and insurance risk appetite framework.
  • Regulatory Adherence: Adheres to underwriting/risk management framework, to the Group's policies, and procedures, satisfying fully all legal and regulatory responsibilities.
  • Service Design: Designs, implements, & monitors the operational services to internal clients.

8. Claims Manager Overview

  • Partner Onboarding: Ensures that new partners are on-boarded onto the service model of Allianz Partners in a timely and efficient manner.
  • Process Optimization: Constantly identifies and executes initiatives to optimize the onboarding to reach Allianz Partners' growth ambitions.
  • Quality Control: Implements quality service control mechanisms (NPS, VOC, etc.) and ensures that they deliver above industry benchmark results through delivering maximum business partner and customer satisfaction.
  • Risk Management: Handles all operational risk and ensures that these are monitored.
  • Culture Leadership: Holds overall responsibility for the culture of claims operations to become an employer of choice.
  • Industry Understanding: Understands the impact of loss costs and the need for leadership in the claims and managed care industry.
  • Claims Development: Develops claims management processes and claims handling procedures for BTE and ATE.
  • Partner Liaison: Liaises with business partners about service provision.
  • Expenditure Monitoring: Monitors claims expenditure to identify and react to trends.
  • Training Leadership: Provides training and development, technical input, and acts as a referral point for all BTE and ATE inquiries about case management and claims handling.
  • Regulatory Compliance: Ensures that the claims team complies with all relevant regulatory requirements and company procedures.
  • Compliance Documentation: Ensures accurate and complete files are kept for each case to demonstrate compliance with FCA rules and facilitate accurate reporting.

9. Claims Manager Tasks

  • Audit Coordination: Coordinate full and specific audit and action plans by standards of performance.
  • Program Direction: Direct the development, implementation, and evaluation of claims and managed care programs, case management, medical bill review.
  • Utilization Management: Manage utilization, preferred provider organizations, and all other programs to improve outcomes and reduce loss costs.
  • Service Administration: Direct the administration of service delivery of claims and managed care programs to clients.
  • Contract Negotiation: Work in conjunction with senior leadership in the negotiation of cost-effective contractual agreements with internal and external service providers.
  • Regulatory Compliance: Ensure the achievement and adherence to all federal, state, and local licensure and regulatory requirements associated with claims and managed care services and programs.
  • Staff Development: Manage and develop staff and partners through coaching, development, training, and quality assurance feedback.
  • Performance Analysis: Conduct ongoing analysis on all aspects of outcome and goal achievement by business plan goals and initiatives.
  • Financial Management: Achieve all financial goals and objectives for the claims and managed care department.
  • Program Improvement: Evaluate, implement, manage, and improve all facets of the claims and managed care programs.
  • Regulatory Monitoring: Monitor all developments in each assigned jurisdiction and make necessary statutory and regulatory changes to improve programs.
  • Claims Standards Maintenance: Maintain world-class claims handling standards based on opportunities within the claims and managed care industry.

10. Claims Manager Roles

  • Technical Supervision: Supervise and provide technical oversight to a medium-sized team of Construction general liability professionals to deliver superb claims results for clients.
  • Performance Management: Ensure performance objectives and metrics are in place to support and meet department goals.
  • Strategic Partnership: Partner with key Claims Management to develop strategic and operational plans aimed at achieving efficiencies.
  • Leadership Training: Provide direction, leadership, and training to in-house claims professionals.
  • Program Development: Establish, refine, and evolve best-in-class claim management program operating characteristics, measurement criteria, and meaningful metrics benchmarking.
  • Claims Strategy: Provide advice and oversight into claim disposition strategies.
  • Collaboration: Work closely with claims adjusters and outside counsel.
  • Litigation Management: Ensure cost-effective and appropriate litigation management strategies are in place that will lead to the best overall outcome.
  • Budget Management: Manage expenditures to budget/plan.
  • Continuous Improvement: Drive continuous improvement through initiatives involving the employees, processes, and technology.
  • Professional Development: Support the professional claims selection process to retain claims professionals who consistently demonstrate appropriate technical expertise, maturity, and a professional commitment to excellence and customer service.
  • Compliance Maintenance: Maintain licensing, professional designations, and continuing education requirements.
Relevant Information
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