The Skills and Training of a Claims Manager

Most claims administration operations strive for consistency and accuracy in benefit provision. They also work hard to achieve these results with a low cost of claims. To accomplish this, they develop and establish policies and procedures for claims handling, hire and promote staff, and audit for compliance.

Yet, within many claims operations (insurance companies, self- administered, and TPAs), their results significantly differ by claims office.

Why?

Usually, the difference in results is due to the claims manager’s relative skill and experience. Unfortunately, there is little formal training for many of the skills the claims manager requires in our industry. I believe there should be a formal training program for each skill necessary to be a great claims manager.

The claims manager position requires a wide variety of skills and knowledge. The essential job in a claims office is the claims manager. As the claims manager goes, so goes the office.

A partial list of skills and duties for the claims manager includes the following:

• Delegation skills.
• People skills, including how to select employees and how to motivate them.
• Ethics.
• Customer relations skills (insurance brokers, vendors, insureds, self-insureds, senior management, and different operations within the company are each unique customers requiring special handling skills).
• High level of claims technical skills, including the practical application of the current law’s rules and regulations on day-to- day cases (often more than one jurisdiction).
• An in-depth understanding of medicine that includes evidence- based diagnosis, treatment, and medical-legal evaluations.
• Vendor management skills include Attorneys, Subrosa, AOE/COE Investigators, Photocopiers, Vocational Rehabilitation, and MSA. From this comes the management of the 1099 process (reporting the payments made to the vendors to the franchise tax boards.)
• An in-depth understanding of process management skills, including establishing claims workflows and information management (this allows the manager to determine how to control and manage the caseloads for the claims examiners).
• Knowledge of human resources, including how to reward, hire, fire, and discipline employees within the company HR culture (every company has different processes for these activities).
• IT technical skills, including maximizing the utilization of the company claims system and hardware technical skills, allowing problem-solving for printing problems. And an understanding of how to implement security access for new employees.
• Knowledge of local State and Federal laws, rules, and regulations that are not necessarily directly related to claims handling but apply to day-to-day processes, such as HIPAA, SAS 70 requirements, and federal terrorism reporting requirements.
• An understanding of the subrogation process.
• A basic knowledge of actuarial data gathering and triangles.
• An understanding of general insurance issues such as excess insurance retentions, how to deal with other insurance companies.
• Analytical skills to develop reports to identify causes for both good and bad trends or results.
• An understanding of actuarial triangles and an ability to read and utilize an actuary report.
• How to identify, report, and prosecute internal and external fraud.
• Negotiations skills.
• An understanding of contracts and contract law.
• A basic understanding of how AI is, and can, impact claims processing.

The claims managers of today will become the next leaders in the insurance industry.

The claims manager’s role is paramount in driving the success and efficiency of claims administration operations. There is a clear need for comprehensive training programs tailored to the specific skills and responsibilities of claims managers. This includes not only technical expertise in claims handling but also people management, delegation, ethics, vendor management, HR processes, IT proficiency, legal knowledge, and analytical skills.

Of all these skills, delegating, managing people effectively, and upholding ethical standards are paramount for claims managers to achieve optimal results. Transitioning from a supervisor to a claims manager often poses challenges, particularly in mastering the art of delegation. However, with proper training and support, claims managers can learn to delegate gracefully and empower their teams to excel.

Companies that recognize the importance of claims managers, invest in succession planning, and provide tailored training programs for supervisors will gain a significant competitive advantage in the Industry.

By prioritizing the development and training of claims managers, companies can ensure long-term success, operational efficiency, and excellence in claims management practices.