Manager, Insurance Quality Assurance Claims (QA / Inspector / Audit)

Roles & Responsibilities

- Conduct regular audits of claims files (Open File Reviews and Closed File Reviews) to ensure adherence to company policies, regulatory requirements, and best practices.
- Monitor the accuracy and consistency of claims decisions, payments, and settlements to ensure compliance with internal quality standards.
- Identify errors in claims processing, including miscalculated payments, incorrect documentation, or missed deadlines, and provide feedback for correction.
- Ensure that claims handling teams follow established SOPs and provide recommendations for updates when necessary.
- Ensure claims handling processes comply with relevant legal and regulatory frameworks, including insurance laws, consumer protection regulations, and data privacy standards.
- Compare the company’s claims handling performance against industry benchmarks and best practices to identify areas for improvement.
- Monitor the cost-efficiency of claims operations, including analysis of loss adjustment expenses (LAE) and claims-related overhead, to optimize resources.
- Identify areas where claims handlers need additional training or support based on quality control audits and analytics results.
- Monitor customer feedback and satisfaction metrics related to the claims process to identify areas for improvement.
- Analyze customer complaints related to claims handling and help implement corrective actions to prevent recurrence.
- Analyze vendor performance (e.g., legal firms, repair shops) in claims processes, ensuring they meet the company's quality and service standards.
 

Candidate Specifications

• Bachelor’s degree in Insurance or other related field.
• Minimum 7 years of relevant experience in the insurance industry with more than 5 years of experience in a Claims Adjusting and Claims Handling role.
• Strong analytical skills to evaluate claims data and identify trends, discrepancies, and areas for improvement.
• Attention to detail to ensure thorough reviews of claims documentation and adherence to policies and procedures.
• Proficiency in data analysis tools and software to generate reports and metrics related to claims performance and quality.
• Effective communication skills to convey findings and recommendations to stakeholders and collaborate with other teams.
• Knowledge of regulatory standards and industry best practices to ensure compliance in claims handling.
• Problem-solving skills to identify root causes of quality issues and develop strategies for corrective actions and process improvements.