Responsible for performing all necessary functions to properly review and audit in-house, off shore claims and ensure that claims are processed in accordance with policy provisions, department procedures and guidelines, and satisfy state department regulations. Facilitates the development of a highly skilled and technical workforce by developing training and conducting training sessions to in-site and off-shore claim examining staff on current and new procedures and products including proper handling of telephone inquiries. Assists in the identification of methods and procedures which will enhance the overall standards of quality in claims processing.
45% Audit on-site, off shore, TPA , and vendor claims selected for review. Ensure that claims are processed in accordance with policy provisions,department policies, and procedures and state regulations.
15% Audit phone calls for accuracy of information and adherence to procedures and guidelines concerning privacy and tone.
10% Construct and manage statistical reports for all audited claims. Analyze quality results to determine trends or opportunities for improvement and publish recommendations and reports to department manager.
10% Communicate results and conduct department and one on one coaching/training sessions with examiners.
10% Assist in the creation and maintainenance of training manuals and guidelines for current and new procedures and products for on-site and off-shore staff. Disseminates changes in procedures and products in a timely manner via written documentation and formal training process.
5% Identify and implement procedures to enhance the overall quality of claims processing.
5% Assist the Quality Assurance Technicians in the handling of referrals and appeals as needed.
American International Group - 8 months ago
Even to this day American International Group (AIG) is one of the world's largest insurance firms. While it held the spotlight...