Quality Analyst

Claims Quality Analyst

Role Purpose:

The primary responsibility of this role is to audit claims to ensure compliance with the Company’s Operational Guidelines (COG) standards.

Key Responsibilities:

• 1.    Conduct thorough audits of claims to assess compliance with COG standards and internal policies.
• 2.    Review and analyze claims documentation, ensuring accuracy and completeness.
• 3.     Identify discrepancies, errors, and areas for improvement in claims processing.
• 4.    Prepare detailed reports on audit findings, including trends and recommendations for corrective actions.
• 5.    Collaborate with claims processing teams to provide feedback and training on quality standards and best practices.
• 6.    Monitor and track the implementation of corrective actions and improvements based on audit findings.
• 7.    Stay updated on industry regulations, standards, and best practices related to claims processing and quality assurance.
• 8.    Assist in the development and refinement of quality assurance processes and tools.
• 9.     Participate in regular quality review meetings and contribute to continuous improvement initiatives.
• 10.    Support the Manager in special projects and initiatives as needed.
• 11.    Supports Claims trainer in conducting product training.
• 12.    Conduct audits of claims during new hire training certification exams.

Experience:

•     Minimum of [3] years of experience in claims processing, auditing, or quality assurance within the insurance or healthcare industry.
•     Strong understanding of claims management processes and COG standards.
•     Excellent analytical and problem-solving skills with a high attention to detail.
•     Proficient in using claims management software and Microsoft Office Suite (Excel, Word, PowerPoint).
•     Strong communication skills, both written and verbal, with the ability to present findings clearly and effectively.
•     Ability to work independently and collaboratively in a team environment.
•     Ability to develop and implement appropriate claims management strategies and plans.
•     Sound knowledge of claims administration procedures and related systems.

Qualifications:

•    Tertiary Qualified or minimum 3-4 years similar work experience 
•    Claims Insurance background is required