JOB DETAILS

JOB DETAIL

• Conduct regular audits of claims files (Open File Reviews and Closed File Reviews) to ensure adherence to company policies, regulatory requirements, and best practices.
• Monitor the accuracy and consistency of claims decisions, payments, and settlements to ensure compliance with internal quality standards.
• Identify errors in claims processing, including miscalculated payments, incorrect documentation, or missed deadlines, and provide feedback for correction.
• Ensure that claims handling teams follow established SOPs and provide recommendations for updates when necessary.
• Ensure claims handling processes comply with relevant legal and regulatory frameworks, including insurance laws, consumer protection regulations, and data privacy standards.
• Compare the company’s claims handling performance against industry benchmarks and best practices to identify areas for improvement.
• Monitor the cost-efficiency of claims operations, including analysis of loss adjustment expenses (LAE) and claims-related overhead, to optimize resources.
• Identify areas where claims handlers need additional training or support based on quality control audits and analytics results.
• Monitor customer feedback and satisfaction metrics related to the claims process to identify areas for improvement.
• Analyze customer complaints related to claims handling and help implement corrective actions to prevent recurrence.
• Analyze vendor performance (e.g., legal firms, repair shops) in claims processes, ensuring they meet the company's quality and service standards.

REQUIRED WORK EXPERIENCE

• Bachelor’s degree in Insurance or other related field.
• Minimum 7 years of relevant experience in the insurance industry with more than 5 years of experience in a Claims Adjusting and Claims Handling role.
• Strong analytical skills to evaluate claims data and identify trends, discrepancies, and areas for improvement.
• Attention to detail to ensure thorough reviews of claims documentation and adherence to policies and procedures.
Proficiency in data analysis tools and software to generate reports and metrics related to claims performance and quality.
• Effective communication skills to convey findings and recommendations to stakeholders and collaborate with other teams.
• Knowledge of regulatory standards and industry best practices to ensure compliance in claims handling.
• Problem-solving skills to identify root causes of quality issues and develop strategies for corrective actions and process improvements.