Job Title: Claims/QC Auditor
Reports to: Claims Supervisor, Senior Claims/QC Auditor, Office Manager
or Assistant Office Manager
Purpose: Audit claims to assure accurate and timely payment and to test the work product of claims adjusters.
Essential Job Duties and Responsibilities:
Performs claims auditing functions, including but not limited to:
• Opening claims, assigning claim numbers, entering claims data into computer, etc. in a timely manner.
• Checking losses to ensure that all supporting documentation is included and auditing claims according to established guidelines.
• Entering loss information on computer system.
• Confirming accuracy of information against error listings and corrects errors.
• Referring problem files to appropriate supervisor or manager.
• Answer questions from adjusters, agents, field staff, and insures about claim status and procedures.
• Generating and distributing various reports, such as claim forms, claim progress reports, and loss drafts.
Performs various quality control functions, including but not limited to:
• Generating quality control documents, reports and distributing as directed.
• Entering completed quality control reviews on computer system.
• Informing appropriate staff of the review process and results.
• Making changes in policies as necessary to reflect QC audit results.
• Maintaining records of agent and adjuster training hours as necessary.
Assist with other duties as necessary.
Knowledge, Skills, and Abilities
Ability to learn and apply detailed information about the Company’s products, services, processes and systems.
Ability to organize and prioritize multiple tasks.
Ability to work in a team oriented environment.
Ability to effectively communicate and maintain business relationships with Company personnel, outside resources and customers.
Ability to comprehend agents’ questions and concerns with regard to claims and to provide correct, courteous answers.
Ability to learn and use the company’s terminology, procedures and systems.
Ability to learn and develop skills in the use of department equipment.
Ability to perform basic and complex mathematical calculations.
Ability to remain calm and professional during peak periods of activity.
Ability to work from oral and written communication.
Ability to maintain confidentiality.
Ability to assist in other work-related areas as required.
Physical and Mental Demands
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
High School or GED required and at least 6 months as an Claims/QC Assistant at Rain and Hail or at least one year of previous underwriting or claims auditing experience or a baccalaureate degree.
This is not necessarily an exhaustive list of the job duties and requirements associated with this job, but is intended to represent an accurate reflection of the current job.
The ACE Group is one of the world’s largest multiline property and casualty insurers. With operations in 53 countries, ACE provides...