Manager Claims Business Controls

Responsibilities

• Own the QA operating system for Claims (TFR automation + manual QAR deep dives), including methodology, sampling, calibration, and thresholds; ensure weekly/Monthly cadence and transparent reporting to leaders.
• Standardize QAR categories (e.g., Communication & Documentation, Coverage/Investigation, Cost Control) and ensure alignment with automated TFR attributes.
• Run cross‑LOB calibration (AB/APD/Casualty/Property) to improve consistency, and embed phone call audit where required.
• Turn QA into action: deliver unit and adjuster‑level insights to Operations for coaching, and track actions to closure without using QAR as performance management.
• Build and lead the Claims audit program for MGAs/DUAs and subscription programs.
• Maintain the Claims Procedures Manuals (end‑to‑end file handling standards, authorities, audits, vendor protocols) and ensure updates are synchronized across LOB manuals and the Corporate Procedures Manual.
• Embed 'file must speak for itself' standards for documentation, privacy, and compliance; spot‑check adherence through routine internal reviews.
• Design and execute first‑line control testing (beyond TFR/QAR) focused on leakage controls, authority use, reserve discipline, SLA adherence, and data integrity.
• Partner with leaders on action plans and evidence packs; track remediation to timely closure and prevent repeat findings.
• Act as Claims SME and single point of contact for external audits and reviews (e.g., reinsurer audits, KPMG/EY financial audits, SOC2/IT‑control touchpoints that affect Claims workflows). Coordinate request lists, samples, walkthroughs, and management responses.
• Serve as Claims lead for KRIs: define thresholds aligned to Risk Appetite, publish monthly dashboards, and escalate breaches with root‑cause and mitigation.
• Represent Claims at ERM/Risk Champions forums; maintain evidence in corporate risk tools and ensure linkage to issue/mitigation programs.
• Coordinate regulatory readiness and control attestations that touch Claims processes (privacy, fair treatment, complaint handling, etc.).
• Lead a small team (e.g., QA Analysts / Business Controls Analysts), set goals, develop capability, and manage workload planning.
• Champion a culture of insightful, forward looking, sustained health reporting in line with the Claims strategy.

Requirements

• A minimum of 7 years in a leadership or managerial capacity within the insurance sector is essential. This experience ensures familiarity with the nuances and intricacies of leading teams, managing operational workflows, and handling the challenges unique to the insurance domain.
• Familiar with all Claim's lines of businesses with hands on experience with Quality Assurance within Claims. Familiarity with internal and external audit requirements to ensure the organization is meeting the required standards.
• Given the regional focus, an in-depth understanding of Canada's insurance regulations, market trends, and customer behaviours is crucial. This knowledge aids in ensuring compliance,

Benefits

Additional Information

At Gore Mutual, we've always set ourselves apart as a modern mutual that does good. Now, we're proudly building on that legacy to transform our company-and our industry-for the better. Effective January 1, 2026, Gore has joined Beneva-the country's largest mutual insurance company-as part of its Property & Casualty operations in Ontario and Western Canada. During 2026, Gore will combine its operations with Unica Insurance, Beneva's Ontario-based subsidiary specializing in niche commercial and personal insurance, creating a stronger, more diversified mutual insurer with greater scale and long-term stability. Every decision and investment remains anchored in long-term benefits to customers, members, and communities. Come join us. As the Manager, Claims Business Controls , you will own the end‑to‑end Claims Business Control Environment, driving a proactive, data‑driven first‑line control strategy that enhances customer outcomes, elevates quality, and optimizes loss cost performance. In this role, you'll lead quality assurance across all lines of business, strengthen processes and procedures, and oversee control testing, audits, and risk programs to ensure strong governance and continuous improvement within Claims.

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