Claims Quality Specialist II

Specialized Services QA Claims is searching for a Claims Auditor to join our Specialized Services QA Team! This role involves audits related to both external vendors and internal nurse case managers, as well as external Utilization Review vendors. You will analyze claims files with the objective of providing critical claims handling feedback to a number of key stakeholders, including the Claims Vendor Management team. The right candidate will bring proven leadership skills, strong analytical skills, effective communication skills, and the requisite technical skills and experience. This position reviews and analyzes claim files to determine compliance with vendor handling guidelines, programs and procedures, as well as participates in calibration training and development of audit results reports.

This is a remote position; however, candidates residing within 50 miles of a GRS claims office will be required to work onsite twice a month. Please note that this policy is subject to change.

Please Note:

• Consideration will be provided to candidates who may qualify for either a Grade 13 or a Grade 14 position, depending on experience level.
• WC experience is preferred
• RN experience and license is required.

Responsibilities:

• Assesses quality assurance and is part of the team responsible for providing quality assurance to Commercial Insurance (CI) Claims Regions and/or Departments and other market partners.
  
  
• Reviews and analyzes claim files to determine compliance with claim handling Quality Standards, programs and procedures. Participates in calibration training and development of audit results reports.
  
  
• Analyze organizational quality assurance results through detailed and timely audits to ensure compliance with internal and external controls. Inform all concerned CI Claims partners of identified quality assurance results using clear, consistent and accurate reports
• Provides feedback to QA Lead Auditor prior to calibration training sessions with Commercial Insurance Claim locations.
  
  
• Ensures audit reports (secondary reviews for QA), are completed timely, tracked, and distributed to the appropriate CI Claims management and other involved parties. Audits include but are not limited to the Monthly Suite of Quality Assurance Reports, Laser Audits, Focus Audits, etc.
  
  
• Consults with QA management to provide appropriate Commercial Insurance Claims management with meaningful remediation/action plans for all quality assurance reports and other audit issues as appropriate.
  
  
• Assists in delivering training to assist Commercial Insurance (CI) Claims Regions and/or Departments in understanding quality assurance
  
  
• Elevates continued quality assurance to proper levels of QA management.

• Responsible for serving as a dedicated liaison to specific Regions or Offices, offering a Quality Assurance perspective on local LMS initiatives, and building strong relationships through cooperative efforts with assigned Commercial Insurance (CI) Claims Regions and/or Departments. While travel to regions is not routine, occasional trips may be required, such as for off-site department meetings.

• Performs other duties as assigned.