AVP - Corporate Claims (Audit and Oversight)

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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...