Senior Insurance Operations Quality Assurance Specialist

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

📋 Description

• Perform a specified number of daily quality audits for assigned departments.

• Assess work for accuracy, completeness, and adherence to company policies, procedures, and relevant regulatory requirements.

• Execute audits across Claims, Customer Service, New Business, Underwriting, and Policy Services.

• Carry out ad hoc and specialized audits.

• Record audit findings and results in Quality Audit databases.

• Audit intricate, high-risk, and non-standard Supplemental Health claims.

• Interpret and apply policy provisions, benefit requirements, limitations, exclusions, and plan language.

• Evaluate claim handling from initial review to final resolution.

• Analyze information, identify inconsistencies or missing documentation, and determine if claim decisions are substantiated.

• Detect processing errors, recurring patterns, root causes, and opportunities for operational improvement.

• Provide feedback to leadership and collaborate with operational leaders on corrective actions and process enhancements.

• Assist in the development, implementation, and refinement of Quality Audit programs.

• Support audit procedures for new products, systems, and services.

• Align audit procedures with business processes, policies, industry standards, and regulatory obligations.

• Aid the Audit Manager with training, coaching, calibration exercises, and technical guidance.

⛳️ Requirements

• High School Diploma or GED.

• Over 3 years of health claims experience.

• Strong knowledge of claims processing workflows and Supplemental Health claim administration.

• Ability to interpret policy provisions, benefit requirements, limitations, and exclusions.

• Exceptional attention to detail with strong analytical and critical-thinking capabilities.

• Competence in evaluating complex information and exercising sound judgment.

• Excellent written and verbal communication skills.

• Previous experience in Quality Audit or Quality Assurance is preferred.

• Experience in auditing complex Supplemental Health claims is preferred.

• Familiarity with providing technical guidance, training, or calibration support is preferred.

• Advanced skills in claims analysis.

• Knowledge in quality assurance and auditing.

• Expertise in policy and benefit interpretation.

• Proficiency in root-cause analysis.

• Understanding of regulatory and procedural compliance.

• Skills in data and trend analysis.

• Ability in coaching and knowledge sharing.

• Commitment to operational excellence and continuous improvement.

🏝️ Benefits

• Eligibility for bonuses.

• Special rates and benefits for educators (company offering).