Claims Quality Auditor audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. Selects claims through random processes and/or other criteria. Being a Claims Quality Auditor makes recommendations to improve quality, workflow processes, policies and procedures. Typically requires an associate degree. Additionally, Claims Quality Auditor typically reports to a supervisor or a manager. The Claims Quality Auditor gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Claims Quality Auditor typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Job
Summary:
This position is responsible for
the oversight of complex and large exposure losses and will report to the
National Casualty & Audit Manager. This position will not only participate
both general and targeted audits but will also review audits performed by
claims management, ensuring that compliance with best practices is achieved. In
addition, this position will report findings and make recommendations on
current practices including the claim department’s performance on meeting
regulatory standards.
Job
Responsibilities:
· Responsible for providing guidance and direction to claims staff
in order to ensure proper handling and risk mitigation.
· Responsible
for collaboration with claims staff, front line claims management, senior
claims management and legal counsel.
· Available
to answer questions and participate in roundtable discussions with claims staff
and management to provide feedback and guidance on claim handling procedures.
· Complete research pertaining to complex coverage
issues, industry trends, and related topics.
· Responsible
for independent audits of each functional area within claims to ensure that
handling is within best practice guidelines.
· Perform
targeted audits, which may include a particular process or function (e.g. total
loss handling, BI evaluations, cycle times, regulatory reviews, customer
service skills, etc.).
· Review
managers’ completed audits to verify calibration and accuracy of the first
level reviews completed.
Qualifications:
Required
· A minimum
of five (5) years adjusting claims including at least two (2) years adjusting
claims with high complexity.
· Bachelor’s
Degree.
Preferred
· Prior
Claims Management Experience.
Core Competencies:
· Must be able to work in a fast-paced automated production
environment.
· Must employ
excellent communication/interpersonal and customer service skills.
· Leadership
abilities are necessary, with the ability to make autonomous decisions based on
multiple facts.
·
Demonstrated team building and coordination skills.
·
Demonstrated ability to partner with management to identify and address
operations, customer service, and underwriting issues.
· Solid
planning and organizational skills including time management, prioritization,
and attention to detail.
·
Demonstrated ability to accomplish goals through influence management.
· Direct,
results driven, and dedicated to the success of the business and each other.
Qualifications:
Required
· A minimum of five (5) years adjusting claims
including at least two (2) years adjusting claims with high complexity.
· Bachelor’s
Degree.
Preferred
· Prior Claims
Management Experience.
Core
Competencies:
· Must be able to
work in a fast-paced automated production environment.
· Must employ
excellent communication/interpersonal and customer service skills.
· Leadership
abilities are necessary, with the ability to make autonomous decisions based on
multiple facts.
· Demonstrated team
building and coordination skills.
· Demonstrated
ability to partner with management to identify and address operations, customer
service, and underwriting issues.
· Solid planning
and organizational skills including time management, prioritization, and
attention to detail.
· Demonstrated
ability to accomplish goals through influence management.
· Direct, results
driven, and dedicated to the success of the business and each other.
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