Workers' Compensation Delegated Claims Audit Specialist
Kalepa Insurance Services, LLC
- # Workers' Compensation Delegated Claims Audit SpecialistApplyremote type: Hybridlocations: OH-Cincinnati: GA-Atlantatime type: Full timeposted on: Posted Yesterdayjob requisition id: JR-000899MSIG USA continues to grow!**Company Overview:**MSIG USA is the US-based subsidiary of MS&AD Insurance Group Holdings, Inc., one of the world’s top P&C carriers and a global Class 15 insurer, with A+ ratings and a reach that spans 40+ countries and regions. Leveraging our 350-year heritage, MSIG USA brings the financial strength, expertise, and global footprint to offer commercial insurance solutions that address your business’s unique risks.**Position Summary**The Workers’ Compensation Delegated Claims Audit Specialist conducts comprehensive audits of workers’ compensation claims administered under delegated authority by third-party administrators (TPAs) on behalf of the company and its insureds/clients. The role evaluates the quality, accuracy, compliance, and financial integrity of delegated claim handling, ensuring adherence to company guidelines, client-specific service instructions, jurisdictional statutes, and industry best practices. Findings are used to drive corrective action, mitigate loss leakage, and support TPA performance management.**Key Responsibilities*** Perform file-level and program-level audits of workers’ compensation claims handled under delegated authority by TPAs, applying standardized scoring criteria and audit protocols.* Evaluate compliance with multi-jurisdictional WC statutes, regulations, mandatory filing/EDI requirements, and state fee schedules.* Assess accuracy of indemnity benefit calculations, including average weekly wage, waiting periods, TTD/TPD/PPD/PTD, and benefit rate application.* Review medical management activities — bill review, PPO penetration, utilization review, nurse case management, and pharmacy/formulary controls.* Evaluate reserve adequacy, reserve rationale, and timeliness of reserve adjustments against exposure.* Audit investigation quality, compensability decisions, three-point contact, and timeliness of initial benefit payments.* Review litigation management, defense counsel oversight, litigation budgets, and settlement authority compliance.* Assess subrogation/recovery identification and pursuit, including excess/reinsurance and Second Injury Fund recovery where applicable.* Identify fraud indicators and evaluate appropriateness of SIU referrals.* Verify Medicare compliance, including Section 111 reporting, conditional payment resolution, and MSA handling where applicable.* Confirm adherence to delegated authority limits, claim handling guidelines, and escalation/reporting requirements.* Document audit results in clear written reports with scoring, root-cause analysis, and actionable corrective recommendations.* Track remediation, validate corrective actions, and conduct re-audits as needed.* Identify trends and systemic handling issues across files; report findings to leadership and contribute to TPA scorecards and stewardship reviews.* Support new TPA onboarding/baseline audits and client-driven special audits.**Required Qualifications*** 5+ years of workers’ compensation claims adjusting and/or claims audit experience.* Demonstrated multi-jurisdictional WC handling knowledge across multiple states.* Strong understanding of statutory benefits, reserving methodology, medical management, and litigation/settlement practices.* Adjuster license(s) as required by applicable jurisdictions (or ability to obtain).* Proficiency with claims systems, audit tools, and Microsoft Office (Excel, Word).**Preferred Qualifications*** Bachelor’s degree.* Professional designations such as WCCP, AIC/AIC-M, ARM, SCLA, or CPCU.* Prior experience auditing TPAs or working within a carrier/self-insured delegated claims oversight function.* Experience with EDI/state reporting requirements and Medicare Secondary Payer compliance.**Core Competencies*** Strong analytical and critical-thinking skills with high attention to detail.* Excellent written communication; able to produce clear, defensible audit reports.* Sound judgment and objectivity; comfortable delivering constructive findings.* Ability to manage multiple audits independently and meet deadlines.* Professionalism and tact in interactions with TPAs, clients, and internal stakeholders.It's an exciting time for our company and a great opportunity to join a financially sound and growing global insurance group!It is the policy of MSIG USA to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, MSIG USA will provide reasonable accommodations for qualified individuals with disabilities.
- J-18808-Ljbffr Kalepa Insurance Services, LLC
Vacancy posted 3 days ago
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