Overview:
Objective
To oversee, enhance, and ensure the quality and accuracy of claims processing, contributing to operational efficiency, compliance, and customer satisfaction.
Scope of Work
The Claims QA Leader will be responsible for developing and implementing quality assurance processes for AmTrust's internal and TPA claims operations. They will oversee audits, analyze trends, and collaborate with teams to improve accuracy, compliance, and efficiency in claims processing.
Responsibilities:
Quality Assurance Oversight
* Develop and implement quality assurance (QA) standards and best practices for claims handling alongside our claim leaders.
* Monitor and evaluate the accuracy of claims adjudication, identifying discrepancies and leakage.
Auditing and Compliance
* Conduct routine and ad-hoc audits to ensure compliance with regulatory and organizational standards.
* Report audit findings and prepare actionable reports for leadership.
* Create calibration process to ensure standards are equally measured.
Training and Development
* Create training programs and materials to address performance opportunities identified through audit.
* Mentor and coach claims staff on quality assurance protocols and best practices.
* Develop training to address and cut down on leakage.
Performance Monitoring
* Establish and track key performance indicators (KPIs) for claims quality.
* Collaborate with teams to set realistic goals and track progress over time.
Process Improvement
* Analyze claims data to identify trends and areas for improvement.
* Work with cross-functional teams to recommend and implement process enhancements.
Stakeholder Communication
* Act as the primary liaison between QA and claims department teams to resolve issues.
* Present QA findings and improvement initiatives to leadership and stakeholders.
* Ability to drive best in class claims handling results through collaboration with department heads.
Goals and Benchmarks
Short-Term Goals (First 3-6 Months)
* Develop and implement a audit framework for claims handling.
* Conduct baseline audits to establish performance metrics.
* Train claims staff on QA processes and compliance requirements.
Medium-Term Goals (6-12 Months)
* Achieve a claims audit score of 90% or higher.
* Identify and address the recurring quality issues in claims handling.
* Reduce leakage rate by at least 5% through targeted training and process improvements.
Long-Term Goals (12+ Months)
* Maintain a consistent claims accuracy rate of 90% or higher.
* Achieve a leakage rate of less than 3%.
* Implement advanced analytics tools for QA monitoring.
Deliverables
* Quarterly QA performance reports, including trends, benchmarks, and actionable recommendations.
* Comprehensive training materials for claims teams.
* Updated QA protocols and workflows.
* Action plans to address recurring claims processing errors.
Performance Evaluation
Success in this role will be measured by:
* Achievement of defined accuracy and compliance benchmarks.
* Reduction in claims leakage.
* Positive feedback from internal teams and stakeholders.
* Consistent delivery of actionable insights and process improvements.
Qualifications:
* Thorough understanding of laws, principles of coverage, liability and insurance industry in general.
* Analytical and human relations skills are critical.
* Leadership skills; ability to plan, organize, delegate and develop staff.
* Effective communication skills; ability to obtain and deliver information to others orally and in written form.
* Ability to work with little supervision and direction.
* Ability to operate business technology.
* College degree or 10 years equivalent experience and skills required.
#LI-REMOTE
#AmTrust
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