Senior Claims Quality Assurance Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform regular audits and evaluations of quality management systems and claims handling procedures.

• Examine claim files to ensure compliance with regulatory standards, statutory obligations, and internal protocols.

• Assess claims for conformity with Claims Best Practices and quality benchmarks.

• Review claim documentation, investigative methods, reserve adequacy, and settlement strategies.

• Detect non-compliance issues and suggest corrective measures.

• Utilize auditing methodologies and sampling techniques.

• Record audit results and create detailed reports for management review.

• Analyze data to uncover trends, patterns, and areas for improvement.

• Provide constructive feedback to adjusters and Claims leadership.

• Maintain documentation of audits, findings, and corrective action plans.

• Create and revise quality control policies and procedures.

• Propose process enhancements and support the implementation of new quality standards.

• Oversee corrective and preventive measures and monitor remediation progress.

• Collaborate with external auditors as necessary.

• Keep abreast of regulatory developments and industry best practices.

• Train staff and mentor adjusters on quality assurance, claims management, and compliance.

• Develop specialized training programs based on audit outcomes.

• Collaborate with Claims Adjudication, Regulatory Compliance, Learning & Development, and Data & Analytics teams.

• Convey quality trends and suggested actions to Claims leadership.

⛳️ Requirements

• High School diploma or GED is mandatory; a Bachelor's degree in Business Administration, Risk Management, or a related field is preferred.

• A minimum of 8 years of experience in workers' compensation claims.

• At least 3 years of experience in claims auditing, quality assurance, or compliance roles is preferred.

• A minimum of 2 years of experience in California workers' compensation claims is required.

• Strong understanding of Claims Best Practices and regulatory requirements across various jurisdictions.

• Proven experience in conducting claim file reviews and documenting audit results.

• Must reside and work in the United States, excluding territories.

• Access to dependable, high-speed internet is essential.

🏝️ Benefits

• Competitive cash compensation.

• Comprehensive health insurance plans.

• Generous paid time off (PTO).

• Future-oriented 401k matching.

• Generous parental and caregiver leave policies.

• Discretionary bonuses may be awarded to eligible team members.

• Core values are actively reflected in the work environment.