This position is responsible for measuring adherence to claim adjudication best practices in order to ensure quality claim handling identify specific learning or training opportunities and reduce financial leakage.  The position serves as a primary resource to conduct target risk-based audits, which drive improved quality assurance, customer experience, policy retention and sales. This resource will also support other Global Risk Management led quality audits and risk management functions, where needed.

RESPONSIBILITIES: 

Conduct monthly post-payment audits of claims randomly selected from all claims paid.   Identify accuracy results at the individual, unit and department levels.   Review claims management audit results for calibration of QA results at the department level Maintain QA database with results identified for monthly quality metric reports.  Serve as local expert to field claims offices in the identification and communication of issues or observations.  Provides Senior Management with detailed documentation to evidence these findings.  Provides effective communication with claims management regarding trends and recommendations for training to support adherence to claims best practice outcomes.  Consult with other departments (e.g. Legal and Compliance), internal and external auditors as required to assess information and audit findings. Other activities assigned by management.

COMPETENCIES:

Quality and customer centric orientation Analytical with excellent decision making skills Strong attention to detail Prior experience in a fast paced, production environment Excellent oral and written communication skills Self-starter Ability to work independently with minimum direct supervision

 

SKILLS/EXPERIENCE: equivalent

Able to learn and quickly apply technical knowledge to insurance products and practices. Ability to use MS Office, Excel, Access and web-based applications.  Windows based PC knowledge Experience with PC based online claim processing systems and/or imaging systems helpful.

 

KNOWLEDGE

Medical terminology, desirable Insurance courses - ICA, AHIP, LOMA desirable 3-5 years’ experience in life, accident or health claims Previous operational audit experience, desirable Risk management experience, desirable

 

EDUCATION:  

Associates or Bachelor’s Degree preferred or equivalent insurance industry experience  (required)