Claims Quality Assurance Specialist

About the role

The Claims Quality Assurance Specialist plays a critical role in ensuring the accuracy, compliance, and efficiency of the claims processing function within the organization. This position is responsible for conducting detailed audits and reviews of claims to identify errors, inconsistencies, and opportunities for process improvement. The specialist collaborates closely with claims adjusters, underwriters, and other stakeholders to provide actionable feedback and support training initiatives that enhance overall claims quality. By maintaining rigorous quality standards, this role helps to minimize financial risk and improve customer satisfaction. Ultimately, the Claims Quality Assurance Specialist contributes to the integrity and reliability of the claims operation, supporting the organization's commitment to excellence and regulatory compliance.

Responsibilities

• Perform comprehensive audits of claims files to assess accuracy, completeness, and adherence to company policies and regulatory requirements.
• Identify trends and root causes of errors or discrepancies in claims processing and recommend corrective actions to management.
• Collaborate with claims teams to provide feedback, coaching, and training aimed at improving claims quality and operational efficiency.
• Develop and maintain quality assurance documentation, including audit checklists, reports, and performance metrics.
• Monitor compliance with internal controls and external regulations, escalating issues as necessary to ensure timely resolution.

Requirements

• Minimum Qualifications: Bachelor’s degree in Business, Insurance, Risk Management, or a related field. Minimum of 3 years of experience in claims processing, quality assurance, or a related insurance function. Strong knowledge of insurance claims procedures, industry regulations, and compliance standards. Proficiency in using claims management software and Microsoft Office Suite. Excellent analytical, organizational, and communication skills.
• Preferred Qualifications: Professional certifications such as AIC (Associate in Claims) or CPCU (Chartered Property Casualty Underwriter). Experience with data analytics tools and techniques to support quality assurance initiatives. Familiarity with regulatory requirements specific to the insurance industry in the United States. Demonstrated ability to lead quality improvement projects or initiatives. Experience working in a remote or hybrid work environment.