Claims Quality Assurance and Compliance Specialist
Job Description
We are seeking a detail-oriented and analytical individual to join our team as a Specialty Claims Quality Assurance and Compliance Specialist.
This role will report to the VP, Specialty Claims Compliance. You will be responsible for ensuring that insurance claims processes adhere to regulatory requirements and internal quality standards.
The ideal candidate will possess strong analytical skills, attention to detail, and a comprehensive understanding of Specialty insurance claims best practices, procedures and compliance regulations.
Responsibilities
What you will do :
- Assist in the implementation of a QA platform for auditing, reporting and the tracking of action plans.
- Review Specialty insurance claims documentation and processes to ensure accuracy, completeness, and compliance with established standards and best practices.
- Conduct audits and analysis of claims data to identify trends, discrepancies, and areas for improvement.
- Collaborate with cross-functional teams to resolve quality issues.
- Develop and deliver compliance training programs for claims processing staff on regulatory requirements and best practices.
- Stay informed about changes in regulatory requirements, industry trends, and best practices.
- Ensure internal claims adjusters are properly licensed.
- Prepare comprehensive reports on quality assurance and compliance activities, highlighting areas for improvement and compliance status.
- Identify opportunities for process optimization and efficiency gains within claims processing workflows.
Qualifications
What you need to have :
- Five to seven years of experience in insurance claims management, compliance, or similar role within insurance.
- Strong knowledge of specialty lines of insurance, insurance regulations, and relevant state and federal laws.
- Strong analytical skills with the ability to interpret complex data and identify trends.
- Attention to detail and accuracy in documentation and analysis.
- Proficiency in Microsoft Office Suite and claims process software.
- Exceptional communication and interpersonal skills, with the ability to collaborate effectively across departments.
- Professional certification in insurance, compliance, or a related field is preferred.
- Ability and willingness to travel as needed.
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