Key Responsibilities and Required Skills for Claims Manager

🎯 Role Definition

The Claims Manager is responsible for overseeing the full claims lifecycle from first notice of loss (FNOL) through closure, ensuring timely, compliant, and profitable claim outcomes. This role manages a team of adjusters and support staff, establishes reserves and settlement strategies, coordinates with legal counsel and external vendors, enforces quality standards and SLAs, and partners with underwriting, risk, and finance to identify trends and control loss costs. The Claims Manager drives continuous improvement in claims operations through analytics, training, fraud control, and technology adoption.

📈 Career Progression

Typical Career Path

Entry Point From:

Senior Claims Adjuster / Complex Claims Specialist
Claims Supervisor / Team Lead
Loss Control / Risk Analyst

Advancement To:

Claims Director / Head of Claims
Vice President, Claims Operations
Chief Claims Officer / Chief Operating Officer (insurance carriers)

Lateral Moves:

Risk Manager / Risk Control Lead
Underwriting Manager / Product Line Manager
Customer Experience / Policyholder Advocacy Lead

Core Responsibilities

Primary Functions

Lead and manage the day-to-day claims operations for assigned lines (personal lines, commercial property, GL, auto, workers’ compensation, or specialty), ensuring all claims are handled promptly, accurately, and in accordance with company policies and regulatory requirements.
Supervise, mentor, and develop a team of claims adjusters, examiners, and support staff; conduct regular performance reviews, set KPI targets (e.g., cycle time, severity, average loss per claim) and implement coaching plans to raise technical competency and productivity.
Oversee the claim reserving process by establishing, reviewing, and adjusting case reserves and loss development assumptions in partnership with actuarial and finance teams to ensure adequate but efficient reserving practices.
Approve complex or high-value claim settlements and litigation strategies; negotiate with claimants, counsel, and third parties to reach fair, defensible settlements while protecting company financial outcomes and reputation.
Manage large-loss and catastrophic (CAT) response activities, coordinating mobilization of field adjusters, temporary staffing, vendor networks, and communications to support surge volume and rapid resolution.
Drive subrogation and recovery efforts by identifying recoverable exposures, assigning subrogation actions, tracking recoveries, and coordinating with legal counsel and external recovery vendors to maximize return on loss dollars.
Oversee Special Investigations Unit (SIU) referrals and fraud detection workflows; review suspicious claims, authorize investigations, coordinate evidence gathering, and ensure timely referral for criminal or civil action when warranted.
Develop and maintain relationships with external service providers including independent adjusters, appraisal firms, body shops, contractors, medical bill review vendors, and defense counsel; negotiate rates, SLAs, and vendor performance standards.
Ensure compliance with state and federal insurance regulations, statutory filing requirements, privacy laws (e.g., HIPAA where applicable), and internal audit controls; implement corrective actions from audits and regulatory exams.
Implement and optimize claims technology and workflow systems (CMS/TPA platforms, imaging, EDI, predictive modeling) by partnering with IT to streamline intake, triage, assignment, and payment processes.
Analyze claims data and trends using reports and dashboards to identify root causes of loss, cost drivers, and opportunities for underwriting collaboration, pricing adjustments, or risk mitigation programs.
Create and deliver training programs and knowledge-sharing sessions on coverage interpretation, liability assessment, negotiation techniques, and litigation management to standardize claims handling across the team.
Establish and enforce quality assurance programs and claims file review procedures to ensure documentation completeness, coverage rationale, medical bill management, and defensible decisions on exposures and payouts.
Collaborate with underwriting, product, and actuarial teams on loss control initiatives, product improvements, endorsement language, and claims cost forecasting to support profitability goals and competitive positioning.
Prepare and present monthly and quarterly claims performance reports to senior leadership and stakeholders including claims run rates, reserve adequacy, loss ratios, large loss summaries, and vendor ROI analyses.
Manage claims department budgets, including staffing levels, vendor spend, legal costs, and vendor contracts; implement cost control initiatives without compromising service quality or compliance.
Lead complex coverage analyses and coverage opinion drafting in coordination with legal to ensure consistent handling of coverage disputes and to protect the company’s contractual positions.
Coordinate litigation management: select and oversee defense counsel, set litigation budgets, monitor case status, evaluate settlement vs. trial strategies, and ensure effective discovery and case preparation.
Serve as escalation point for high-profile, sensitive, or litigated claims and handle communications with brokers, large account clients, regulators, and corporate executives as needed to manage stakeholder expectations.
Design and oversee process improvement projects (Lean, Six Sigma or similar) to reduce claim cycle time, lower average severity, improve subrogation capture, and enhance claimant satisfaction scores (NPS/CSAT).
Review and manage reinsurance and excess claims reporting requirements; prepare required documentation and participate in reinsurance recoveries and reconciliations.
Ensure medical management practices for bodily injury claims (e.g., IME coordination, medical bill review, utilization review) are applied to control medical spend and return-to-work outcomes in workers’ comp or GI exposures.
Implement and monitor KPIs and SLAs for responsiveness, file closure rates, payment accuracy, and customer satisfaction; introduce corrective action plans where targets are not met.
Drive a culture of customer-centric claims service by setting standards for claimant communication, empathy, transparency, and timely resolution to preserve insurer reputation and retention.

Secondary Functions

Participate in cross-functional projects (IT implementations, digital claims initiatives, client onboarding) and act as the subject-matter expert for claims processes and workflows.
Support enterprise risk management by contributing claims trend analysis and loss drivers to enterprise risk registers and mitigation plans.
Assist with recruitment, onboarding, and workforce planning to ensure appropriate staffing levels during normal and peak claim periods.
Contribute to business continuity and disaster response planning for claim operations, including backup staffing, remote work protocols, and vendor contingency arrangements.
Provide ad-hoc executive briefings and post-mortem analyses following significant loss events, regulatory inquiries, or major litigation outcomes.

Required Skills & Competencies

Hard Skills (Technical)

Claims lifecycle management: FNOL intake, investigation, coverage analysis, reserving, negotiation, settlement, and subrogation.
Reserve analysis and financial acumen: ability to set and audit case reserves and understand the impact on loss triangles and company loss ratios.
Regulatory and compliance knowledge: familiarity with state insurance laws, P&C regulations, workers’ compensation rules, privacy (HIPAA) and anti-fraud statutes.
Litigation and legal management: experience managing outside counsel, preparing for trial, and understanding discovery/e-disclosure processes.
Vendor and vendor-contract management: negotiating rates, SLAs, performance monitoring for third-party administrators, independent adjusters, and medical vendors.
Claims management systems and data tools: hands-on use of major CMS platforms, MS Excel (pivot tables, VLOOKUP), BI tools (Power BI, Tableau), and EDI integrations.
Subrogation and recovery processes: identifying recoverable claims, managing recovery workflows, and maximizing financial recoveries.
Medical cost management and IME oversight for bodily injury and workers’ compensation claims.
Catastrophe (CAT) response planning and surge operations management for high-volume events.
Quality assurance and audit: ability to design and execute claims file reviews, root-cause analysis, and remediation plans.

Soft Skills

Strong leadership and people management with experience coaching, motivating, and developing high-performing claims teams.
Exceptional negotiation and conflict resolution skills with a track record of effective settlements and claimant communications.
Excellent oral and written communication skills for stakeholder reporting, coverage opinions, and sensitive claimant interactions.
Analytical mindset with the ability to synthesize claims data into actionable insights and presentable metrics for senior leadership.
Decisiveness under pressure and strong judgement to make defensible coverage and settlement decisions.
Customer-centric orientation and empathy in handling claimants and insureds while balancing company interests.
Project management and change management skills to lead process improvement and technology implementation initiatives.
Attention to detail and strong organizational skills to maintain compliant and audit-ready claims files.
Collaboration and cross-functional partnering with underwriting, actuarial, finance, and IT teams.
Ethical conduct and integrity, particularly in fraud detection, SIU referrals, and sensitive litigation matters.

Education & Experience

Educational Background

Minimum Education:

Bachelor's degree in Business, Risk Management, Insurance, Finance, Legal Studies, or a related field (or equivalent professional experience).

Preferred Education:

Bachelor’s degree plus insurance designations (CPCU, AIC, ARM, NCCI certificates) or a master’s degree in business administration, risk management, or law.

Relevant Fields of Study:

Risk Management and Insurance
Business Administration / Finance
Legal Studies / Paralegal Studies
Healthcare Administration (for heavy medical or workers’ comp roles)

Experience Requirements

Typical Experience Range:

5–10+ years of progressive claims experience with at least 2–4 years in a supervisory or management role.

Preferred:

7–12 years in property & casualty claims management with demonstrated experience in litigation management, SIU/fraud, subrogation, CAT response, and vendor management. Prior experience with commercial lines or specialty lines (e.g., directors & officers, cyber, marine) is a plus.