Workers' Compensation Delegated Claims Audit Specialist

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.