Quality Assurance Specialist (Claims Support) (Hybrid)

The Quality Assurance Specialist reviews and evaluates samples of claim files for compliance with Best Practices and State Regulations. Aiding in the company meeting the prompt and fair settlement loss standards, within the provisions of the insuring agreement and all applicable insurance regulations. They are responsible for creating value in the review process by identifying areas of opportunity for improvement and/or training in individual reviews and claim processes. They communicate all findings in a professional, effective and supportive manner with examiners and management.

Duties & Responsibilities: 

• Perform Focus Audits to check for compliance as requested by management.
• Applicable divisional Regulation reviews.
• Reg 118 reviews.
• ISO System to System Audits.
• Review samples of claims for valid and applicable coverage.
• Review claims for proper coverage verification.
• Determine loss exposure and appropriate reserves as applicable.
• Review and analyze documents received on the claim.
• Determine areas of opportunity for improvement and identify training opportunities.
• Perform review of internet-based processes that may be applicable.
• Review process changes for Best Practice or Regulation compliance.
• Effectively communicate findings including root cause analysis and provide suggestions on a corrective course of action with all interested parties.
• Remain current on procedural changes in the division that affect their area of review.
• Review claim files and document findings on file memos and compile reports for management review.
• Maintain current knowledge base of existing and emerging regulations, standards, guidance documents, and internal procedures.
• Additional duties as assigned.

Requirements:

• High School Diploma
• 3 years of industry experience OR an Associates Degree

Skills & Qualifications:

• Working knowledge and understanding of NYS Regulations as applicable to the division.
• Full working knowledge and understanding of basic insurance principals, insurance policies, and claims procedures.
• Proficient personal computer skills including electronic mail, record keeping, routine database activity, Microsoft Word, PowerPoint and Excel.
• Excellent and effective oral and written communication skills.
• Effective time management skills.
• Detail oriented.
• Strong decision-making skills.
• Active learner.
• Adaptable, approachable, and kind.
• Ability to work both independently and within a team with minimal direct supervision.
• Critical Thinking.
• Engaged and enthusiastic.
• Ability to accept, absorb and promote change.
• Willingness to engage in authentic conversations.
• Places high value on proactive divisional communication and partnerships.
• Organized; Ability to multi-task and prioritize.
• Ability to build positive professional working relationships.
• Ability to handle stress professionally, calmly, and effectively.
• Positive and professional attitude.

Market Range 5 / 37.5 hours per week / Hybrid

Salary: $41,156- $57,563

Accepting applications through: 12/25/25

 

A leading insurer focused on claims processing and risk management.