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About the Role
The Claims Operations Governance & Solutions Specialist supports the development, implementation, enhancement, and ongoing effectiveness of claims systems and related operational processes. This role leads discovery, requirements gathering, business analysis, bordereau mapping, testing, implementation, and enhancement activities in collaboration with various stakeholders. The position also supports the Director, Claims Operations in administering third-party administrator (TPA) audits and selected governance activities.
Responsibilities
- Lead assigned claim discovery, requirements gathering, business analysis, and workflow-assessment activities, and support IT in solution design and development.
- Translate operational and claims-handling needs into documented business requirements, system requirements, process flows, mapping specifications, validation rules, test scenarios, and implementation materials.
- Work collaboratively with the Manager, Claims Operations, Claims Handlers, IT/ Systems, vendors, and other stakeholders to ensure system solutions support operational, technical, reporting, and control requirements.
- Support new-program implementation by assessing system and workflow requirements, coordinating bordereau mapping, contributing to configuration decisions, and preparing testing and implementation documentation.
- Support the deployment of new systems and enhancements and coordinate testing activities.
- Lead the analysis and mapping of bordereaux for new and existing programs.
- Document source data, field definitions, transformation requirements, validation rules, exceptions, and expected system outputs.
- Collaborate with Manager, Claims Operations to confirm that mapping and system outputs reflect actual processing requirements.
- Coordinate mapping testing, investigate discrepancies, and support remediation.
- Support the Director, Claims Operations in administering the TPA audit program.
- Assist with audit planning, scope development, information requests, audit schedules, evidence tracking, sample preparation, and audit templates.
- Conduct assigned pre-work, file reviews, fieldwork, control testing, evidence assessment, and documentation.
- Maintain remediation trackers and follow up on agreed corrective actions, supporting evidence, due dates, and closure status.
- Assist the Director, Claims Operations in managing selected governance activities, including TPA audit remediation tracking, annual SOP and workflow review coordination, control evidence collection, and reporting.
- Monitor assigned review dates, action items, evidence requirements, and remediation commitments, and escalate delays or gaps.
- Develop and maintain SOPs, workflows, process maps, and supporting documentation for the Manager’s assigned system, TPA audit, and governance responsibilities.
- Support the development or revision of broader Claims Operations SOPs and workflows when assigned by the Director, Claims Operations.
- Assist with coordinating the annual review of Claims SOPs and workflows.
- Maintain sufficient working knowledge of claims intake, assignment, bordereau review and processing, reconciliations, delegated and fronting program structures, policy mapping, loss-fund processes, and related operational workflows.
- Collaborate with the Manager, Claims Operations to understand operational requirements, validate system and workflow solutions, supporting testing and implementation, and ensure enhancements are practical and executable.
- Maintain sufficient claims-handling knowledge to understand how coverage, reserves, settlement authority, financial activity, escalations, and TPA handling requirements affect systems, workflows, reporting, mapping, and controls.
Requirements
- 5+ years of progressive experience in claims operations, claims handling, delegated authority, TPA oversight, insurance systems, or insurance operations.
- Experience supporting systems discovery, requirements gathering, process mapping, bordereau mapping, testing, implementation, or system enhancement activities.
- Experience with claims bordereaux, operational reporting, process documentation, audit administration, file reviews, or control testing.
- Experience supporting fronting, MGA, DUA, or TPA-administered programs is preferred.
- Strong knowledge of the claims lifecycle, settlement authority, reserves, bordereau reporting, delegated-authority controls, and the interaction between Claims Operations and Claims Handling.
- Ability to translate operational and claims-handling requirements into system requirements, mappings, process flows, test scenarios, SOPs, and implementation materials.
- Strong analytical, organizational, documentation, facilitation, project-coordination, and stakeholder-management skills.
- Ability to work collaboratively.
- Ability to define business requirements for operations reports and support the development of report specifications and outputs.
- Advanced proficiency in Microsoft Excel and experience with dashboards, reporting tools, claims systems, testing, data mapping, and document repositories.
Skills
- Microsoft Excel
- Dashboards
- Reporting tools
- Claims systems
- Testing
- Data mapping
- Document repositories
Location
- Toronto
Work Type
- Hybrid
Experience Level
- 5+ years
Education Level
- Post-secondary education in insurance, business, operations, technology, or a related field, or an equivalent combination of education and experience.
- Chartered Insurance Professional (CIP) designation or equivalent industry education is preferred.
Salary/Compensations
- $80,000 - $95,000
Benefits
- Flexibility
- Authenticity
- Growth opportunities
- Exposure to strategic decision-making and business planning
About the Company
- Tokio Marine Canada (TMCan) is a Canadian early-stage entrepreneurial commercial P&C insurer based in Toronto.
- We partner with select brokers to deliver tailored business insurance solutions across Canada.
- As part of the Tokio Marine Group, we are able to collaborate under a shared framework while maintaining autonomy and local decision-making.
- We support Canadian businesses in taking smart risks by delivering practical insurance solutions and exceptional service through trusted broker partnerships.
- At TMCan, we’re a relationship company.
- We value collaboration, innovation, and inclusion, where every voice matters and every team member makes an impact.
- We believe in flexibility, authenticity, and growth: because when our people thrive, so does our business.
- TMCan offers the unique opportunity to work side by side with senior leaders, gaining direct exposure to strategic decision-making and business planning.
- Our CARE values guide everything we do: Collaborative, Achieving Excellence, Responsive, Ethical & Respectful.
Equal Opportunity
- At TMCan, we are deeply committed to fostering a culture of equity, diversity, and inclusion.
- We strive to create a workplace where every individual is welcomed, respected, and valued for their unique identity and perspective.
- By embracing our differences and learning from one another, we aim to build a positive and empowering environment for all.
- Tokio Marine Canada was proudly recognized as one of the Best Places to Work in Canada by Canadian HR Reporter in 2024.