Clinical Quality Assurance Associate II
About The Position
Clinical Quality Assurance Associate II Continental General - Austin, Texas Looking to join a growing company dedicated to helping others? We offer that, plus competitive salaries, a culture of learning, and a fast-paced environment. Join our team to help make a difference in the lives of others! About Continental General: The Continental General family of companies has provided insurance, including life and long-term care policies, to individuals and groups for over 30 years, and currently supports over 100,000 policyholders. Both our insurance company, Continental General Insurance Company, and our third-party administrator, Continental General Services, are committed to the continuous development of our infrastructure, processes, and people. The group is actively growing through expansion of both its insurance portfolio and its administrative services. With each opportunity, we take a collaborative approach to address challenges and provide unique solutions. Position Overview: A Quality Assurance Associate is essential in maintaining the quality, consistency, and compliance of all inbound LTC claims. They proactively identify risks, minimize exposure, and provide expert guidance on policy interpretation and regulatory requirements. Their expertise, rooted in their RN background, is invaluable in delivering critical insights and informed guidance.
Requirements
- 5+ years of related experience in claims management and review, with experience in the insurance industry and with related products a plus.
- Must hold a current RN license.
- Possesses a high level of technical knowledge and skills related to claims management and review
- Communicates effectively, both orally and in writing, with empathy and strong listening skills.
- Performs work under limited supervision.
Responsibilities
- Supports the Claims Department through regular claim reviews for quality, consistency, and compliance: Evaluates performance through pre and post disbursement file reviews and re-reviews.
- Evaluates the acuity of individual producers using defined criteria and provided tool(s).
- Uses knowledge of the LTC Claim Lifecycle and Regulations to evaluate the handling of LTC Claims across multiple clients.
- Working knowledge of written SOPs for managing and maintaining LTC claims across multiple clients.
- Understands and has strong skills in identifying risk and reducing exposure.
- Acts as a SME, advising on Policy interpretation and regulation guidance, or ascertaining guidance from Compliance and/or Internal/External Legal.
- Compiles quality data and regularly performs training needs analysis, process improvement needs, gaps, and other risk exposure.
- Works closely with Senior QA members and Training Unit to inform on individual and departmental training needs and facilitates monitoring of accuracy and consistency post training/implementation.
- Assists in gathering quality metric data for Senior QA and QA Manager.
- Provide input on potential referrals for the Special Investigation Unit (SIU).
- May assist in the review of and/or responses to complex claims, complaints, regulatory inquires, and litigated matters.
- Assists with testing as needed.
- Assists with input on SOPs as needed.
- Other duties as assigned.
- Supports Business Objectives with External Claim Audit and Consulting Engagements: Uses knowledge of the LTC Claim Lifecycle and Regulations to evaluate the handling of LTC Claims for external clients.
- Acts as a SME, advising on Policy interpretation and regulation guidance, or ascertaining guidance from Compliance and/or Internal/External Legal.
- Assists in identifying risk exposure and gaps through file reviews.
- Uses defined criteria and provided tool(s) for completing file reviews.
Benefits
- Competitive Salary & Target Bonus Program
- Retirement Savings – 401(k) with a company match
- Comprehensive Medical insurance through BlueCross BlueShield of Texas.
- Company-paid dental, vision, short-term & long-term disability, and life insurance.
- Work-Life Balance – This role offers 25 days of PTO, 10 paid holidays, and paid volunteer time off.
- Flexible Work Options & Perks – Hybrid opportunity, wellness programs, and weekly paid lunch for onsite staff.
- Health Savings Accounts (HSA) & Flexible Spending Accounts (FSAs) – Includes a company match for HSAs.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
