Senior Claims Quality Assurance Auditor
About The Position
The Senior Claims Quality Assurance Auditor conducts regular audits and assessments of Pie’s claims handling processes to ensure compliance with Claims Best Practices, regulatory standards, statutory requirements, and internal guidelines. The role reviews claim files, identifies non-compliance, and recommends corrective actions to improve claims quality. It also collaborates with Claims teams, prepares audit reports, and supports quality-control policies and training programs to promote continuous improvement and regulatory compliance. The auditor evaluates claim documentation, investigation techniques, reserve adequacy, and settlement practices using established audit methodologies and sampling techniques. Responsibilities include documenting findings, analyzing trends, providing feedback to adjusters and Claims leadership, maintaining audit and remediation records, and monitoring corrective actions for lasting improvement. The role also develops and updates quality procedures, supports external audits, delivers training and coaching, and partners with Claims Adjudication, Regulatory Compliance, Learning & Development, and Data & Analytics teams. This is a remote role unless otherwise specified. Remote team members must live and work in the United States, excluding territories, and have reliable, high-speed internet access.
Requirements
- High school diploma or GED required.
- At least 8 years of workers’ compensation claims experience, with a strong understanding of claim handling practices.
- At least 2 years of California workers’ compensation claims experience required.
- Strong knowledge of Claims Best Practices and regulatory requirements across multiple jurisdictions.
- Experience conducting claim file reviews and documenting audit findings.
Nice To Haves
- Bachelor’s degree in Business Administration, Risk Management, or a related field preferred.
- At least 3 years of experience in claims auditing, quality assurance, or compliance roles preferred.
Responsibilities
- Conduct regular audits and assessments of quality management systems and claims handling processes.
- Review claim files for compliance with regulatory standards, statutory requirements, internal guidelines, and Pie’s Claims Best Practices.
- Assess claim documentation, investigation techniques, reserve adequacy, and settlement practices.
- Identify non-compliance and recommend corrective actions.
- Apply audit methodologies and sampling techniques to conduct comprehensive evaluations.
- Document audit findings, deficiencies, and observed best practices.
- Prepare management audit reports with findings, recommendations, and action items.
- Analyze data to identify trends, patterns, and improvement opportunities across the claims organization.
- Provide timely feedback to adjusters and Claims leadership and maintain records of audits, findings, and corrective action plans.
- Collaborate with departments to maintain consistent quality standards.
- Develop and update quality-control policies and procedures in response to audit findings and regulatory changes.
- Assist in setting quality-assurance goals and objectives aligned with department strategies.
- Recommend process improvements and support implementation of new quality standards and best practices.
- Monitor corrective and preventive actions, track remediation, and verify sustained improvements in claims quality.
- Coordinate with external auditors and facilitate external audit processes when needed.
- Stay current on regulatory changes and industry best practices affecting claims quality.
- Train staff on quality-assurance policies, procedures, and industry best practices; coach adjusters on claim handling and compliance.
- Conduct training sessions on common audit findings and remediation strategies and support Claims Learning & Development training content.
- Partner with Claims Adjudication, Claims Regulatory Compliance, Claims Learning & Development, and Claims Data & Analytics teams.
- Communicate quality trends and recommended actions to Claims leadership.
Benefits
- Competitive cash compensation
- Comprehensive health plans
- Generous paid time off
- 401(k) match
- Parental and caregiver leave
- Discretionary bonuses may be granted to eligible team members based on company performance
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
