Claims Quality Assurance Specialist

Overview

This role is offered through a partner company seeking a Claims Quality Assurance Specialist located in the United States. It provides an opportunity for an experienced professional to enhance operational quality, compliance, and overall performance within a fast-paced insurance setting. The position acts as a subject matter expert in claims quality, auditing claim handling procedures, identifying areas for enhancement, and guiding teams via training and strategic insights. The successful candidate will analyze claims data, evaluate processes, and collaborate with leadership to optimize accuracy, efficiency, and service excellence in claims operations. This fully remote role is suited for individuals possessing strong claims knowledge, analytical capabilities, communication skills, and a dedication to ongoing improvement.

Key Responsibilities

• Function as the core technical quality assurance expert for claims operations by verifying adherence to established claim handling standards, industry best practices, and client specifications.
• Perform comprehensive audits on claim files focusing on coverage assessment, investigation thoroughness, valuation accuracy, reserving precision, compliance, and proper claim resolution.
• Lead quality assurance initiatives and serve as the main liaison between operational teams and senior management.
• Assist with developing and implementing quality improvement plans, corrective measures, and operational advancement projects.
• Design, deliver, and upkeep training programs including calibration sessions that emphasize policy, system workflows, regulatory adherence, and best practices.
• Examine quality trends and operational metrics to detect risks, performance shortfalls, and opportunities to enhance processes.
• Oversee claim financial metrics such as reserves, pending transactions, compliance assessments, and potential leakage.
• Provide detailed operational reports featuring insights, suggestions, and corrective action recommendations arising from quality assessments.
• Collaborate with technical and operations divisions to evaluate systems, uncover defects, validate workflows, and propose enhancements to claims processing tools.
• Maintain standards for quality, productivity, and turnaround times ensuring they align continuously with operational goals.
• Engage in strategic discussions with claims leadership to resolve significant deficiencies and elevate performance standards.

Candidate Requirements

• A bachelor's degree in Business Administration, Insurance, Healthcare Management, or a related discipline; or an equivalent blend of education and relevant work experience.
• Minimum of 5 years’ experience in claims management, insurance operations, healthcare claims, third-party administration, or comparable complex claims environments.
• In-depth understanding of the full claims lifecycle encompassing investigations, financial oversight, regulatory compliance, and operational workflows.
• Proven experience in performing quality assurance evaluations, audits, training delivery, and driving process improvements.
• Strong analytical and problem-solving abilities with competence in trend interpretation and translating data into actionable plans.
• Excellent communication skills, both verbal and written, with capability to work effectively with internal teams, leadership, and external partners.
• Demonstrated leadership in coaching, mentoring, and educational guidance, emphasizing continuous improvement over enforcement.
• Competent at managing multiple tasks independently within a demanding operational environment.
• Exceptional organizational, project, and time management skills.
• Proficiency with Microsoft Office and business intelligence/reporting tools.
• High standards of professionalism, tact, and adaptability in dealing with sensitive or complex issues.
• Preferred qualifications include familiarity with quality assurance methodologies, training certification, or claims technology platforms.

Compensation & Benefits

• Competitive salary ranging between $70,276 and $116,942 annually, determined by location, experience, qualifications, skills, and market factors.
• Ability to work fully remotely.
• Comprehensive healthcare package including medical, dental, and vision coverage.
• Options for Health Savings Account (HSA) and Flexible Spending Account (FSA).
• Life, disability, accident, and critical illness insurance plans.
• Participation in 401(k) and Roth 401(k) retirement programs.
• Paid time off plus additional wellness benefits for employees.
• Access to pre-paid legal services and commuter benefits where applicable.
• Career growth opportunities within a stable and expanding organization.
• Supportive work culture emphasizing collaboration, accountability, and professional development.

Additional Information

The application and selection process is managed by the partner company, utilizing AI-supported screening to shortlist candidates based on core qualifications for efficient and unbiased review. Final hiring decisions and further stages such as interviews or assessments are conducted internally by the partner. Applicants' data is processed with adherence to data protection laws and may involve AI tools to assist in candidacy evaluation, while final decisions are human-led.