Claims Quality Assurance Specialist

Job Description The Claims Quality Assurance Specialist performs accurate and timely claim file reviews and supports to define claims guidelines. The role determines coverage, analyzes, negotiates, and settles complex claims requiring outside investigation while delivering quality customer service. The role reviews and implements an appropriate system of policies, internal controls, accounting... standards and procedures, measures efficiency and productivity of claims quality assurance department by clearly defining and reporting results monthly. Responsibilities • Completes accurate and timely claim file reviews, ensures adherence to claims guidelines and jurisdictional requirements, communicates, and promotes the Quality Assurance file review process. • Trains, coaches, and calibrates the Quality Assurance file review system, drives integrity and credibility of the Quality Assurance program and related processes with periodic reviews. • Identifies improvement opportunities and performs quality audits, analyzes, and resolves issues, identifies corrective and preventative action items for the business process. • Updates policies and procedures as needed, ensures adherence to applicable laws and regulations, provides valuable knowledge and guidance around agile testing, and produces timely results hands. • Resolves compliance issues, provides resourcefulness, reliable responses and compliance support to develop consistent policies and procedures across business lines. • Inputs on workflow and system enhancements, increases the efficiency and quality of compliance teams work, shares knowledge around agile testing and performs manual testing as necessary to augment automation. • Drives complex business systems analysis, acceptance testing, quality assurance review, and problem analysis to support products. • Analyzes quality issues, provides feedback, and proposes solutions. • Handles Quality Assurance resource planning, provides quality metrics, attends meetings with business partners and uses quality monitoring data management system to compile and track performance. • Serves as a subject matter expert on cross-functional teams for company-wide initiatives, supervises claims or participates on claims projects and conducts mini-reviews for sub-groups and project teams within Claims. • Determines ongoing training needs and partners with Westfield University, leaders, and external Quality Assurance related vendors to develop, and deliver training programs to claims professionals. • Completes project risk analysis, quality and project timelines to determine the production readiness of software to ensure a smooth transition into production environment. • Participates in professional industry groups, identifies, and communicates industry, legal and regulatory changes, industry advancements, process improvements and best practices. Qualifications • 5+ years of Claims Handling experience and Claims Quality Assurance experience preferred. • Bachelor's degree in Business Administration, Finance, or any other field and/or commensurate work experience. Equal Opportunity Employer Westfield celebrates diversity and is committed to inclusion. All qualified applicants receive consideration for employment without regard to race, color, sex, religion, national origin, age, sexual orientation, gender identity, disability, or status as a protected veteran