Claims Quality Assurance

Accountabilities Serve as the technical quality assurance expert for claims operations by evaluating compliance with established claim handling standards, industry practices, and client requirements.

Conduct detailed audits of claim files, assessing areas such as coverage analysis, investigation quality, claim valuation, reserving accuracy, compliance, and claim disposition.

Lead quality assurance projects and act as a primary point of coordination with operational teams and senior leadership.

Support the development and execution of quality improvement strategies, corrective action plans, and operational enhancement initiatives.

Create, deliver, and maintain quality assurance training programs, including calibration sessions focused on policies, systems, workflows, regulations, and best practices.

Analyze quality trends and operational data to identify risks, performance gaps, and opportunities for improvement.

Monitor claim financial performance, including reserves, pending payments, compliance reviews, and potential claim leakage issues.

Provide operational reporting, including findings, recommendations, and corrective action plans based on quality reviews.

Collaborate with technical and operations teams to test systems, identify defects, validate workflows, and recommend improvements to claims processing tools.

Maintain and update quality, productivity, and turnaround standards while ensuring continuous alignment with operational objectives.

Participate in strategic discussions with claims leadership to address significant deficiencies and improve overall performance.

Requirements

Bachelor’s degree in Business Administration, Insurance, Healthcare Management, or a related field, or equivalent combination of education and relevant professional experience.

5+ years of experience within claims management, insurance operations, healthcare claims, third-party administration, or a similar complex claims environment.

Strong knowledge of end-to-end claims administration processes, including investigations, financial management, compliance requirements, and operational workflows.

Demonstrated experience conducting quality assurance reviews, audits, training sessions, or process improvement initiatives.

Strong analytical, quantitative, and problem-solving skills with the ability to interpret trends and translate findings into actionable recommendations.

Excellent written and verbal communication skills with the ability to collaborate effectively with internal teams, leadership, and external stakeholders.

Strong leadership, coaching, and mentoring abilities with a focus on education and continuous improvement rather than enforcement.

Ability to manage multiple priorities, work independently, and remain effective in a fast-paced operational environment.

Strong organizational, project management, and time management skills.

Proficiency with Microsoft Office applications and business reporting tools.

High level of professionalism, diplomacy, and adaptability when handling sensitive or challenging situations.

Experience with quality assurance methodologies, training certification, or claims technology platforms is preferred.

Benefits

Competitive salary range of $70,276 – $116,942 , based on location, experience, qualifications, skills, and market conditions.

Fully remote work opportunity.

Comprehensive healthcare benefits, including medical, dental, and vision coverage.

Health Savings Account (HSA) and Flexible Spending Account (FSA) options.

Life insurance, disability insurance, accident insurance, and critical illness coverage.

401(k) and Roth 401(k) retirement plans.

Paid time off and additional employee wellness benefits.

Pre-paid legal services and commuter benefit options where applicable.

Opportunities for career advancement within a stable and growing organization.

Supportive work environment focused on collaboration, accountability, and professional development.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether? 

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