Claims Quality Assurance Specialist

Berkley • Atlanta, GA

13d

About The Position

The Quality Assurance – Claims role is responsible for supporting the VP of Claims through file audits, reserving oversight, and Medicare reporting for the Claim Department. This position will be responsible for conducting reserve reviews, leading and participating in monthly claim file audits and conducting and completing Medicare reporting reviews. The role is responsible for ensuring managers and adjusters comply with all quality standards, compliance requirements and Best Practices set forth by the company. They will also be responsible for maintaining and acting on any projects, audit results and required actions in conjunction with claim leadership and compliance. The ideal candidate will be highly organized and responsive, while consistent in meeting deadlines.

Requirements

• Four (4) year College Degree, JD preferred, or commensurate experience and training.
• Casualty Claims Handling: Proven proficiency in managing claims across all product lines and coverages.
• File Evaluation & Reserve Setting: Strong ability to audit and evaluate claim files and establish accurate reserves.
• Policies & Procedures: Thorough knowledge of organizational policies, claim Best Practices, regulatory requirements, and claims handling processes.
• Technical Claims Expertise: Solid background in coverage and liability assessment, property damage, bodily injury, New York Labor Law, construction defect claims, and management of both non-litigated and litigated matters.
• Collaboration: The ability to work well with others in an affable and collaborative way with the common goal of achieving a state-of-the-art claim service.
• A minimum of seven years of experience handling complex litigated claims in all lines of business.
• A minimum of three years conducting claim file audits.
• Experience with a variety of claim systems including GuideWire’s ClaimCenter and audit tools such as C2Perform and others.
• Technical acumen and working knowledge of Excel.
• Strong coverage knowledge across multiple lines of business including Professional Liability, General Liability, Products, Construction Liability, and Construction Defect.
• Strong knowledge of multiple jurisdictions.
• Strong knowledge of trial process and litigation management.
• 5 years progressive leadership experience in a claim organization.
• Adjuster licenses as required.

Responsibilities

• Conduct File Reviews: Perform structured reviews of claim files to ensure compliance with internal/external requirements and Best Practices, maintaining consistency and objectivity across the Claim Department.
• Assess File Quality, Coverage & Reserves: Identify, document, and evaluate file quality and reserve sufficiency, providing constructive feedback to drive continuous improvement.
• Support SOX Claim Compliance: Assist Claim Leadership in executing SOX compliance initiatives, including reviewing Best Practices, updating SOX Claim Narratives, and testing claim controls (QA, Large Loss, SOPs, Best Practices, Claim Authorities). Contributes to the development of process and procedures to improve audit results.
• Facilitate Calibration Discussions: Partner with claim managers to ensure consistency in claim file reviews, reserving standards, and adherence to Best Practices.
• Ensure Regulatory Compliance: Maintain compliance with applicable Medicare reporting requirements, updating claim files as necessary to ensure accuracy and adherence to all regulations.
• Additional duties as assigned
• Regular and predictable attendance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level