Senior Insurance Operations Quality Assurance Specialist
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Job Description
Senior QA specialist auditing complex Supplemental Health claims for Horace Mann, an educator-focused insurance and financial services company. Analyzing compliance, trends, and process improvements.
Responsibilities:
- Conduct a designated number of daily quality audits for assigned departments.
- Evaluate work for accuracy, completeness, and compliance with company policies, procedures, and applicable regulatory requirements.
- Perform audits across Claims, Customer Service, New Business, Underwriting, and Policy Services.
- Conduct ad hoc and special audits.
- Document audit findings and results in Quality Audit databases.
- Audit complex, high-risk, and non-routine Supplemental Health claims.
- Interpret and apply policy provisions, benefit requirements, limitations, exclusions, and plan language.
- Assess claim handling from initial review through final disposition.
- Analyze information, identify inconsistencies or missing documentation, and assess whether claim decisions are supported.
- Identify processing errors, recurring trends, root causes, and operational improvement opportunities.
- Provide feedback to leadership and partner with operational leaders on corrective actions and process improvements.
- Assist with development, implementation, and refinement of Quality Audit programs.
- Support audit procedures for new products, systems, and services.
- Align audit procedures with business processes, policies, industry standards, and regulatory requirements.
- Assist the Audit Manager with training, coaching, calibration exercises, and technical guidance.
Requirements:
- High School Diploma or GED.
- 3+ years of health claims experience.
- Strong understanding of claims processing workflows and Supplemental Health claim administration.
- Ability to interpret policy provisions, benefit requirements, limitations, and exclusions.
- Exceptional attention to detail and strong analytical and critical-thinking skills.
- Ability to evaluate complex information and exercise sound judgment.
- Strong written and verbal communication skills.
- Previous Quality Audit or Quality Assurance experience (preferred).
- Experience auditing complex Supplemental Health claims (preferred).
- Experience providing technical guidance, training, or calibration support (preferred).
- Advanced claims analysis.
- Quality assurance and auditing.
- Policy and benefit interpretation.
- Root-cause analysis.
- Regulatory and procedural compliance.
- Data and trend analysis.
- Coaching and knowledge sharing.
- Operational excellence and continuous improvement.
Benefits:
- Bonus eligibility
- Special rates and benefits for educators (company offering)
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