The primary responsibility of this role is to audit claims to ensure compliance with the Company’s Operational Guidelines (COG) standards.

Key Responsibilities:

• Conduct thorough audits of claims to assess compliance with COG stand-ards and internal policies.
• Review and analyze claims documentation, ensuring accuracy and com-pleteness.
• Identify discrepancies, errors, and areas for improvement in claims pro-cessing.
• Prepare detailed reports on audit findings, including trends and recom-mendations for corrective actions.
• Collaborate with claims processing teams to provide feedback and training on quality standards and best practices.
• Monitor and track the implementation of corrective actions and im-provements based on audit findings.
• Stay updated on industry regulations, standards, and best practices relat-ed to claims processing and quality assurance.
• Assist in the development and refinement of quality assurance processes and tools.
• Participate in regular quality review meetings and contribute to continu-ous improvement initiatives.
• Support the Manager in special projects and initiatives as needed.
• Supports Claims trainer in conducting product training.
• Conduct audits of claims during new hire training certification exams.

• Minimum of [3] years of experience in claims processing, auditing, or qual-ity assurance within the insurance or healthcare industry.
• Strong understanding of claims management processes and COG stand-ards.
• Excellent analytical and problem-solving skills with a high attention to de-tail.
• Proficient in using claims management software and Microsoft Office Suite (Excel, Word, PowerPoint).
• Strong communication skills, both written and verbal, with the ability to present findings clearly and effectively.
• Ability to work independently and collaboratively in a team environment.
• Ability to develop and implement appropriate claims management strate-gies and plans.
• Sound knowledge of claims administration procedures and related sys-tems.
• Claims Insurance background is required