Claims Quality Assurance Specialist

2 months ago

Mississauga, Ontario, Canada Definity Full time
Job Summary

We are seeking a highly skilled Claims Quality Assurance Specialist to lead the implementation and execution of a technical file review program within the claims area of the business. This role will ensure our claims file handlers and leaders are meeting customer expectations, ensuring case reserves are timely and accurate, managing claims according to regulatory requirements, and adhering to other file handling practices to Economical standards.

Key Responsibilities
  • Work with Claims VPs and Directors, Actuarial and Insurance Risk teams to drive claims handling insights and impact while supporting Claims in their action planning and resolution
  • Report the results of these reviews into 2 new sub-committees (Claims Risk & Control and Reserving committee/sub-committee) to promote a strong risk and control environment
  • Support the development of claims technical file review audit methodology framework and processes
  • Provide input/insight in developing the annual audit plan
  • Support the development of audit quality standards for each step of the audit process such as: testing scripts and interpretation notes, working papers, etc.
  • Complete file reviews
  • Make recommendations on findings, agreeing with key claims stakeholders to appropriately manage risks
  • Report findings to Risk & Reserving committees, senior leaders and other key stakeholders as required
  • Manage internal and external resources supporting this work
  • Recommend and influence any necessary changes to company policies, guidelines and best practices
  • Ensure all reviewers (Claims Leaders, Claims Technical Advisors, Claims Quality Assurance) are calibrated for a consistent approach in auditing claims files
  • Obtain agreement with Claims Leaders and Claims Technical Advisors on establishing best-in-class standards for audit and minimum thresholds for lines of business and file handling performance, including developing leakage methodology
  • Incorporate data analytics to measure and monitor adherence to regulatory and company standards, including idea generation, designing automated testing procedures and investigating potential gaps and incorporating findings into the reporting process
  • Provide advisory and consultative services on claims file management, claims process effectiveness, risk management and control on new initiatives, process changes, existing processes and from ad hoc requests
  • Problem solving from root cause analysis on issues to developing and implementing solutions
  • Work with Claims, Actuarial, Risk, IT, Legal & Compliance, Finance and Underwriting
  • Foster awareness of the company's policies and procedures through regular communication, training and employee engagement
  • Help to implement any new requirements, controls, close action items as needed, including assisting with new regulatory requirements, process and controls mapping/documentation, framework updates and/or development
  • Monitor emerging best practices in risk management, audit and control to improve the organization's ability to identify, assess, mitigate, govern and report
  • Develop techniques to make control testing more efficient and effective
Requirements
  • Strong 5+ years claims career including; 5+ years of Auto Adjusting and/or Auto Claims Appraisal experience
  • Multi-line claims handling experience is an asset but not necessary
  • Experience in audit, risk management, regulatory compliance, processes and controls is preferred but not necessary
  • Experience as a claims leader is an asset but not necessary
  • Strong stakeholder management skills
  • Strong understanding of business operations and related legislative, regulatory and internal policy and procedure requirements
  • Excellent analytical, written and verbal communication skills
  • Ability to build strong relationships externally and internally at all levels to help foster a positive compliance culture
  • Proficient in Excel, Powerpoint and Word
  • Strong organizational and problem-solving skills with the ability to gather information, analyze critically and cut through complexities to arrive at workable solutions
  • Strong level of personal integrity
  • Highly Positive attitude and open minded
  • Thrives in a team environment and ability to also work independently
  • Bilingualism is an asset
About Us

We are Definity, a company that values inclusion, diversity, and equity. We are committed to making insurance better and are seeking a talented Claims Quality Assurance Specialist to join our team.

We offer a hybrid work schedule, company share ownership program, pension and savings programs, paid volunteer days, educational resources, and a focus on inclusion and diversity.

Actual salary for the role may vary depending on work location of the successful candidate and other factors including but not limited to, skills, education, experience, working conditions and the local labour market.

This role requires successful clearance of background checks (including criminal checks and leadership references).

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