Claims Quality Assurance Auditor

The Claims Quality Assurance Auditor will conduct regular audits and assessments of Pie's claims handling processes to ensure adherence to Claims Best Practices, regulatory standards, and internal guidelines. This role is responsible for reviewing claim files for compliance, identifying areas of non-compliance, and recommending corrective actions to improve claims quality. The auditor will collaborate with Claims teams, prepare detailed audit reports, and support the development of quality control policies and training programs that drive continuous improvement in claims performance and ensure regulatory compliance.

Claims Audit & Assessment:

• Collaborate with Claims leadership to design, refine, and continuously improve the quarterly audit program and scoring methodology, ensuring alignment with operational realities while maintaining regulatory defensibility.
• Partner with Claims to define:
• Weighted scoring criteria
• High-risk violation thresholds
• File sampling strategy
• Performance benchmarks tied to ≥95% compliance targets
• Ensure the audit program reflects evolving statutory requirements, regulator audit trends, and internal risk drivers.
• Conduct regular monthly and quarterly  audits and assessments of quality management systems and claims handling processes
• Review claim files to verify compliance with regulatory standards, statutory requirements, and internal guidelines
• Evaluate claims for adherence to Pie's Claims Best Practices and quality standards
• Assess claim documentation, investigation techniques, reserve adequacy, and settlement practices
• Identify areas of non-compliance and recommend corrective actions to address deficiencies
• Apply weighted scoring methodology to measure compliance performance and identify systemic risk patterns.
• Apply established audit methodologies and sampling techniques to ensure comprehensive evaluations

Documentation & Reporting:

• Document monthly and quarterly audit findings with clear, detailed explanations of deficiencies and best practices observed
• Prepare comprehensive audit reports for management that include findings, recommendations, and action items
• Analyze data to identify trends, patterns, and areas for improvement across the claims organization
• Provide timely feedback to adjusters and Claims leadership on audit results
• Maintain accurate records of all audits, findings, and corrective action plans

Quality Control & Process Development:

• Collaborate with various departments to ensure quality standards are met consistently
• Develop and update quality control policies and procedures based on audit findings and regulatory changes
• Assist in developing quality assurance goals and objectives aligned with department strategies
• Recommend process improvements to enhance claims quality and operational efficiency
• Support the implementation of new quality standards and best practices

Compliance & Corrective Action Monitoring

• Monitor the implementation and effectiveness of corrective and preventive actions
• Track remediation efforts to ensure deficiencies are addressed in a timely manner
• Verify that corrective actions result in sustained improvements in claims quality
• Coordinate with external auditors and facilitate external audit processes when needed
• Stay current with regulatory changes and industry best practices that impact claims quality

Training & Knowledge Sharing:

• Train staff on quality assurance policies, procedures, and industry best practices
• Provide coaching and guidance to adjusters on claim handling techniques and compliance requirements
• Conduct training sessions on common audit findings and remediation strategies
• Share knowledge of regulatory requirements and Claims Best Practices with Claims teams
• Support Claims Learning & Development initiatives with quality-focused training content

Cross-Functional Collaboration:

• Partner with Claims Adjudication team to address quality issues and implement improvements
• Work with Claims Regulatory Compliance team to ensure audits capture all compliance requirements
• Collaborate with Claims Learning & Development team to develop targeted training based on audit findings
• Coordinate with Claims Data & Analytics team to support quality reporting and trend analysis
• Communicate with Claims leadership on quality trends and recommended actions

Required Experience & Education:

• High School diploma or GED required; Bachelor's degree in Business Administration, Risk Management, or related field preferred
• 5+ years of workers' compensation claims experience with strong understanding of claim handling practices
• 2+ years of experience in claims auditing, quality assurance, or compliance roles preferred
• Strong knowledge of Claims Best Practices and regulatory requirements across multiple jurisdictions
• Experience conducting claim file reviews and documenting audit findings

The use of AI in Application Review: To support a fair, efficient, and consistent hiring process, we use AI-powered tools to assist in the initial screening of applications. These tools help us identify qualifications and prior work experiences that align with the requirements of the role. We may also use AI assistant video tools during interviews to support note-taking and candidate evaluation. All AI-powered outputs are still subject to human oversight and decision-making at multiple stages of the process. By submitting your application, you acknowledge and consent to Pie utilizing these AI technologies to assist in our evaluation process.