Claims Operations Specialist - HYBRID

Key Responsibilities

• Manage and conduct pre- and post-payment adjudication audits on claim matters to ensure financial, processing, and operational accuracy
• Verify that claim adjudication aligns with policy terms, standard operating procedures (SOPs), and state or federal regulations
• Investigate the underlying causes of errors, overpayments, or underpayments to prevent future recurrence
• Conduct reviews of existing policies, SOPs, and guidelines to ensure relevance, accuracy, and compliance with current laws and industry standards
• Proactively propose updates to policies, SOPs, and guidelines based on audit findings and changing legal requirements
• Handle claims operational setup and compliance frameworks required for business expansion into new states
• Assess claim departmental workflows and results to assist with the development of key performance indicators (KPIs) and evaluation metrics
• Support month-end closings and provide statistical data analysis
• Participate in, with the potential to oversee, system development, maintenance, and support, while collaborating with and managing external vendors
• Ad-hoc projects and other responsibilities as assigned

Qualifications

• 5–7+ years of progressive experience in property and casualty (P&C) claims, with deep industry knowledge and understanding
• Proven experience in a claims auditing, quality assurance, or compliance-focused role, including experience managing or auditing
• Strong knowledge of state and federal insurance regulations, Fair Claims Settlement Practices, and compliance requirements (including Medicare Secondary Payer/Section 111 Reporting)
• Knowledge of operational setup and compliance required for expansion into new jurisdictions
• Demonstrated ability to proactively investigate root causes of errors and propose strategic solutions for quality improvement
• Proficiency in financial data analysis
• Experience collaborating with IT teams and external vendors on system development, maintenance, or process improvement
• Strong written and verbal communication, organization skills, critical thinking, and analytical capabilities
• Bachelor’s degree in Business, Finance, Computer Science, Statistics, or a related field is preferred
• Proficiency in SAP, Power BI, SQL, Python, R, Tableau, Excel, and/or data cleaning is preferred
• Professional insurance designations (e.g., CPCU, AIC) are highly desirable
• Certification from the International Compliance Association or another recognized compliance group is a plus
• Bilingual in Korean is a plus

Benefits

• Medical (PPO), dental (PPO), vision (PPO), and life insurance covered 100% by the company and 50% for dependents
• Paid time off and sick leave
• 13 annual paid holidays
• 401(k) plan with up to 4% company match
• Flexible Spending Account (FSA) & Dependent Care FSA
• Quarterly Fringe Benefit reimbursements
• Job-related training reimbursement
• Casual dress code

About Us

At DB Insurance USA, we carry forward a legacy of excellence that began in South Korea in 1962 and expanded to the U.S. in 1984. Backed by the financial strength of a global powerhouse (AM Best Rating: A+, S&P Rating: A+), we combine world-class resources with the agility of a close-knit team. With offices in California, Hawaii, New York, and Guam, we provide innovative insurance solutions tailored to protect your property, business, and livelihood. We are committed to fostering a culture of inclusion and innovation, ensuring exceptional service and peace of mind for every policyholder.