Sr Insurance Operations Quality Assurance Specialist
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What you'll do
- 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 operational areas including Claims, Customer Service, New Business, Underwriting, and Policy Services.
- Conduct ad hoc and special audits as requested.
- Accurately document audit findings and results within Quality Audit databases.
- Perform comprehensive audits of Supplemental Health claims, including complex, high-risk, and non-routine cases requiring advanced analysis and judgment.
- Interpret and apply policy provisions, benefit requirements, limitations, exclusions, and other plan language when evaluating claim decisions and processing accuracy.
- Apply in-depth claims-processing knowledge to assess claim handling from initial review through final disposition.
- Analyze multiple sources of information, identify inconsistencies or missing documentation, and determine whether claim decisions are appropriately supported.
- Identify processing errors, recurring trends, root causes, and opportunities for operational improvement.
- Provide timely and constructive feedback to leadership regarding audit findings, trends, and departmental performance.
- Partner with operational leaders to recommend corrective actions and process improvements.
What they're looking for
- 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.
Nice to have
- Previous Quality Audit or Quality Assurance experience.
- Experience auditing complex Supplemental Health claims.
- Experience providing technical guidance, training, or calibration support.
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
Horace Mann is seeking an experienced and analytical Senior Insurance Operations Quality Assurance Specialist to help ensure quality, accuracy, and compliance across our Supplemental & Group operations.
In this role, you'll conduct comprehensive quality audits across operational areas while bringing deeper expertise to the review of Supplemental Health claims, including complex, high-risk, and non-routine cases. You'll analyze claim decisions from initial review through final disposition, interpret policy and benefit provisions, identify trends and root causes, and partner with operational leaders to strengthen quality and processes.
This is an excellent opportunity for an experienced health claims professional who enjoys digging into complex cases, identifying opportunities for improvement, and using their expertise to strengthen both individual and organizational performance.
Key Responsibilities
Quality Auditing & Analysis
- 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 operational areas including Claims, Customer Service, New Business, Underwriting, and Policy Services.
- Conduct ad hoc and special audits as requested.
- Accurately document audit findings and results within Quality Audit databases.
Advanced Claims Quality Review
- Perform comprehensive audits of Supplemental Health claims, including complex, high-risk, and non-routine cases requiring advanced analysis and judgment.
- Interpret and apply policy provisions, benefit requirements, limitations, exclusions, and other plan language when evaluating claim decisions and processing accuracy.
- Apply in-depth claims-processing knowledge to assess claim handling from initial review through final disposition.
- Analyze multiple sources of information, identify inconsistencies or missing documentation, and determine whether claim decisions are appropriately supported.
Trends, Root Cause & Continuous Improvement
- Identify processing errors, recurring trends, root causes, and opportunities for operational improvement.
- Provide timely and constructive feedback to leadership regarding audit findings, trends, and departmental performance.
- Partner with operational leaders to recommend corrective actions and process improvements.
- Use audit findings to help strengthen quality, consistency, and customer outcomes.
Quality Program Development
- Assist with the development, implementation, and refinement of Quality Audit programs across business units.
- Support development of audit procedures for new products, systems, and services.
- Ensure audit procedures remain aligned with evolving business processes, company policies, industry standards, and regulatory requirements.
- Assist the Audit Manager with training, coaching, calibration exercises, and technical guidance for auditors and operational employees.
Qualifications & Experience
Required
- 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.
Preferred
- Previous Quality Audit or Quality Assurance experience.
- Experience auditing complex Supplemental Health claims.
- Experience providing technical guidance, training, or calibration support.
Skills & Competencies
- Advanced claims analysis
- Quality assurance and auditing
- Policy and benefit interpretation
- Root-cause analysis
- Critical thinking and sound judgment
- Regulatory and procedural compliance
- Data and trend analysis
- Coaching and knowledge sharing
- Strong attention to detail
- Operational excellence and continuous improvement
Pay Range:
- $57,500.00 - $71,900.00 annually + bonus
Salary is commensurate to experience, location, etc.
Horace Mann was founded in 1945 by two Springfield, Illinois, teachers who saw a need for quality, affordable auto insurance for teachers. Since then, we’ve broadened our mission to helping all educators protect what they have today and prepare for a successful tomorrow. And with our broadened mission has come corporate growth: We serve more than 4,100 school districts nationwide, we’re publicly traded on the New York Stock Exchange (symbol: HMN) and we have more than $12 billion in assets.
We’re motivated by the fact that educators take care of our children’s future, and we believe they deserve someone to look after theirs. We help educators identify their financial goals and develop plans to achieve them. This includes insurance to protect what they have today and financial products to help them prepare for their future. Our tailored offerings include special rates and benefits for educators.
EOE/Minorities/Females/Veterans/Disabled. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status
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Company
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