Claims Quality Assurance

About the role

The Claims Quality Assurance serves as the technical claims expert for the Claims Operations by auditing compliance with established CorVel, industry and carrier claim handling standards. The primary responsibility is evaluating claim handling quality, accuracy, and timeliness in categories including but not limited to: coverage analysis, investigation, valuation, reserving, compliance and accurate disposition of claims.

Essential Functions & Responsibilities

• Model ethical behavior and executes job responsibilities in accordance with CorVel’s core values, ethics, and information protection policies
• Serve as technical QA lead to assigned offices or departments
• Lead QA projects and serve as primary coordinator for senior leadership of assigned offices
• Support the Claims Quality Assurance Program and the EC Operations Team in developing and implementing quality improvement strategies
• Lead the creation, presentation, execution, and calibration of Quality Assurance Training sessions, including integration and delivery of claims training programs in the context of Quality Assurance calibration exercises (e.g. policy, systems, workflows, statutes)
• Report on pending payments, reserves, Adjuster POA/Supervisor review compliance, leakage, and various reports to assess operational performance and compliance to CorVel standards
• Maintain and update in real time quality, quantity, and turn-time standards
• Conduct testing on software, websites, and other technical products to identify and resolve defects, and other potential claims processing issues
• Review claim process specifications to understand the scope, requirements, and function of each product
• Identify appropriate parameters, functions, and data to test and validate; parameters may include general function, validity of results, accuracy, reliability, and compliance with industry standards
• Conduct testing to ensure products perform according to user requirements and within established guidelines; if a product does not perform within specifications, report defects to EC Operations and the BOT teams identifying and recommending solutions, improvements, and updates
• Submit operational QA reporting to EC Ops at durations outlined; operational reporting to include written corrective action plans for areas of deficiency identified during the QA review process
• Participate in strategic operational calls with EC Operations and claims leadership when the QA process has identified a significant operational deficiency
• Work with EC Operations to insert QA corrective action plans required by a carrier or client

Knowledge & Skills

• Excellent written and verbal communication; demonstrated ability to provide superior service to internal and external stakeholders
• Demonstrated ability to provide superior service to internal and external stakeholders
• Effective quantitative, analytical and interpretive skills
• Excellent leadership and mentorship skills, with a demonstrated ability to motivate staff and obtain results through teamwork and education
• Strong proficiency with Microsoft Office applications
• Strong interpersonal, time management, project management, and organizational skills
• Ability to maintain a high level of professionalism
• Knowledge of the entire claims administration processes including ancillary services
• Ability to remain poised in stressful situations and communicate with diplomacy, using written and verbal communication
• Ability to work independently or in a team environment while functioning as an educator rather than an auditor

Education & Experience

• Bachelor’s Degree with course concentration in Business Administration, or related field; or 5+ years of equivalent combination of education and experience in a complex healthcare, insurance, or third-party claim organization with significant claim management expertise
• Significant industry experience and a thorough understanding of CorVel’s proprietary systems and solutions
• Certified Trainer and/or Quality Assurance experience a plus