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.