Claims Quality Assurance Specialist

  • Portland, ME, USA
  • Dec 19, 2018
Full time Insurance

Job Description

The Quality Assurance Specialist’s primary responsibility is to monitor and review claims to ensure compliance with MEMIC’s internal best practices, as well as statutory requirements, and to develop and implement strategies to improve compliance in these areas. In addition, this position may be called upon to assist and support the compliance and training staff in the development of compliance plans and training documentation.

  • Monitors indemnity claim file activity in real time to ensure jurisdictional benchmarks related to timeliness of initial compensability determinations, accuracy of payments and/or denials, and completion of forms over the life of the claim are met.
  • Reviews state specific legal orders to ensure timely response, payment and form filings, when applicable.
  • Reconciles penalties incurred to confirm validity and provides recommendations to Claim Management on the appropriateness of a payment or an appeal, when applicable.
  • Identifies, analyzes, and summarizes trends in results and works with Claim Management and/or Claim Trainers to develop a plan to enhance quality and performance.
  • Completes objections of fee reviews in applicable jurisdictions, follows for and tracks response.
  • Completes state reconciliation in applicable jurisdictions.
  • Retroactively reviews selected indemnity claim files from a compliance perspective and summarizes results by utilizing structured review sheets to objectively demonstrate claim handler’s performance.
  • Assists Compliance Associate with mandatory Medicare reporting data integrity as needed.
  • Assists with quality reviews of Compliance Assistants as needed.
  • Supports compliance team goals by assisting with special projects or tasks as directed by Manager, Claim Compliance.


  • Bachelors Degree with 3-5 years of claim handling experience; multi-jurisdictional experience preferred, or equivalent combination of education and experience.
  • Workers’ Compensation claim handling experience desired.
  • Strong attention to detail, accuracy, and analytical skills are necessary.
  • Excellent interpersonal, written and verbal communication skills are essential.
  • Must be organized with effective time management skills to meet strict deadlines, when necessary.
  • Must have ability to prioritize and focus.
  • Must possess the ability to work effectively in a fluid team environment and self-motivate.
  • Proficient in Microsoft Office.