Worker's Compensation Quality Assurance Manager

Duties and Responsibilities

• Heavy involvement in drafting quality assurance policies and procedures and ability to interpret and implement quality assurance standards based upon review of data

• Conduct regular self-audits of WC claim operations results, processes and workflows to measure compliance and effectiveness
• Document and track claim metrics of our TPA by office/region and providing senior leadership and all claims operation staff with quarterly reports detailing results and action items
• Conduct audits of our TPA’s and internal staff to monitor compliance with policies and best practices
• Ability to break down problem into manageable components
• Can recognize symptoms that indicate problems and develop and implement solutions with minimal oversight
• Ability to work closely with TPA operational and account management personnel
• Must be an effective communicator who can adjust their message and approach to successfully influence up, down and across organizational boundaries

• Evaluate adequacy of quality assurance standards, make changes where warranted

• Devise auditing procedures and directions for recording and reporting quality data

• Review the implementation and efficiency of quality assurance process

• Investigate service complaints and non-conformance issues with TPA and internal staff

• Track, measure, and benchmark all line of business metrics

• Analyze data to identify areas for improvement in the quality system

• Develop, recommend, and monitor corrective and preventive actions

• Prepare reports to communicate outcomes of quality activities

• Identify training needs of both our TPA’s and internal staff and organize training interventions to meet quality standards

• Coordinate and support all line of business audits that will include TPA’s, vendors, and internal audits

• Evaluate audit findings and implement appropriate corrective actions

Qualifications, Knowledge and Experience

To perform this job successfully, an individual must possess advanced technical WC claims knowledge, extensive claims handling and operational claims experience working for an insurance carrier. The successful candidate must have excellent communication skills and have experience making presentations, preparing reports, and implementing training for stakeholders in all levels of a claims organization. In addition to strong analytical and time management skills, this individual should be able to work well independently and as part of a team to meet established deadlines and metrics. The successful candidate will have experience in claims auditing and developing quality assurance programs with extensive experience and positive track record on implementing solutions.

The requirements listed below are representative of the knowledge, skills and/or ability required.

• Extensive knowledge of claims industry best practices, standards and regulations in multiple jurisdictions.
• Ability to handle complex projects and assignments which involve analysis, implantation, and communication of findings to leadership and other stake holders
• Attention to detail and impeccable time management skill required
• Extensive insurance knowledge in Workers’ Compensation (multiple jurisdictions preferred)
• Advanced Excel worksheet skills
• Ability to travel to multiple locations across the county
• Supervisory /leadership experience is required
• Computer Experience with related claims and business software
• 10+ years prior claim experience to include 3+ years in a leadership role

All your information will be kept confidential according to EEO guidelines.