Claims Quality Review Consultant

You have a clear vision of where your career can go. And we have the leadership to help you get there. At CNA, we strive to create a culture in which people know they matter and are part of something important, ensuring the abilities of all employees are used to their fullest potential. 

CNA’s Long Term Care (LTC) business unit isn’t your typical slow moving insurance company; we have the resources of a large company behind us and operate with a start-up mindset. With a team of 50 across multiple insurance disciplines of Operations, Claim, Anti-Fraud, Finance, Actuarial and Data Management, we move quickly and have a clear line of sight into how we make an impact. With approx. $13B in reserves serving 300K policyholders, CNA’s LTC business is an important strategic priority for CNA.

Under technical direction, conducts claim audits, monitors compliance and controls, ensures adherence to Claims Best Practices; consistency, timeliness, and accuracy of claim outcomes; and high levels of customer service. Reviews and makes recommendations regarding claim processes. Assists in the selection, design and implementation of enhancements to improve claim outcomes and integrate processes.

JOB DESCRIPTION:

Essential Duties & Responsibilities

Performs a combination of duties in accordance with departmental guidelines:

• Conduct Quality Assurance audits of insurance claims, in accordance with established strategies and objectives, focusing on:

End to end claim accuracy, consistency and timeliness

Risk mitigation

Adherence to guidelines and operating procedures

Alignment with best practices

• Support senior leadership in the identification of claim trends and opportunities for continuous process improvement. Conduct review of all aspects of claim which may include claim approvals, proposed denials and payments. Ability to identify fraud, waste or abuse in claims with appropriate escalation as needed.

• Participate as needed in review of appeals, escalations, and complaints.  Draft guidelines and implement changes to business processes, workflows, and practices to ensure alignment with CNA expectations.

• Support regulatory changes, market conduct exams and DOI audits, as needed.

• Support training needs in conjunction with overall claim objectives; facilitate and conduct claim training, as needed.

• Draft claim reporting and dashboards, as needed.

• Leveraging data, work closely with senior leadership in the development and implementation of claim policies, business strategies, metrics and goals.

• Regularly evaluate performance against goals, and hold self accountable for achieving desired results.

May perform additional duties as assigned.

Reporting Relationship

Typically Manager or above

Skills, Knowledge & Abilities

• Working knowledge of claim auditing and assigned line of business. Has the ability to analyze, interpret, and present complex problems and solutions to a variety of audiences, demonstrating strong presentation skills.

• Ability to effectively interact and collaborate with all levels of CNA's internal and external business partners, building strong relationships with team members, and proactively raising and addressing issues.

• Strong analytical, critical thinking and problem solving skills, with the ability to effectively plan and manage multiple assignments and audit workload.

• Ability to identify claim opportunities, evaluate options, and recommend optimal solutions.

• Prioritizes claim opportunities and achieves results by taking a proactive, long−term view of business goals and objectives.

• Ability to understand business needs and think through all scenarios and challenges before formulating potential solutions.

• Ability to solve problems with a sense of urgency; able to utilize and manage all available resources to make informed decisions and achieve superior results.

• Demonstrates the knowledge and understanding of when and how to use claim data and metrics to assist in making informed business decisions.

• Exercises professional judgment and assumes responsibility for decisions that impact people and quality of service.

• Ability to creatively and effectively manage through ambiguous and challenging business problems and lead through change while taking appropriate level of risk.

• Knowledge of Microsoft Office Suite and other business-related software systems, including processing systems and applications.

• Meticulous attention to detail in verifying the accuracy of claims and identifying discrepancies or errors.  

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