Claim Quality Review Consultant

3 weeks ago

Reading, United States CNA Full time

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.

Under technical direction, conducts on-site Claim audits, monitors compliance and controls, ensures adherence to Claims Best Practices; consistency, timeliness, and accuracy of eligibility decisions; and high levels of customer service. Reviews and makes recommendations regarding claim decision processes and outcomes. Assists in the selection, design and implementation of system enhancements associated with claim decision and integration of processes to improve claim outcomes.

JOB DESCRIPTION:

Essential Duties & Responsibilities

Performs a combination of duties in accordance with departmental guidelines:

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

  • Decision accuracy consistency and timeliness
  • Risk mitigation
  • Adherence to guidelines and operating procedures
  • Alignment with best practices


Supports senior leadership in the identification of claim trends and opportunities for continuous process improvement. Conducts pre-review of Claim decisions which may include high dollar claim payments and proposed denials.

Participate as needed in response to appeals, escalations, and complaints. Drafts guidelines and implements changes to business processes, workflows, and practices to ensure alignment with CNA expectations.

Supports regulatory changes and impact to operations.

Supports market conduct exams and DOI audits.

Supports local training needs in conjunction with overall Claim objectives; facilitate and conduct common training as needed.

Drafts Claim reporting and dashboards as needed.

Participates with senior leadership in the development and implementation of Claim policies, business strategies, metrics and goals; regularly evaluates performance against goals, and holds 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.

Ability to effectively interact and collaborate with all levels of CNA's internal and external business partners, possessing strong communication and presentation skills.

Strong analytical, critical thinking and problem solving skills, with the ability to effectively plan and manage multiple projects and project work teams with an eye for Claim innovation.

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.

Education & Experience

Bachelor's Degree or equivalent work experience

Typically a minimum of five years of related work experience.

#LI-AR1

#LI-Hybrid

In certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In California, Colorado, Connecticut, New York and Washington, the national base pay range for this job level is $49,000 to $98,000 annually. Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees - and their family members - achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA's benefits, please visit cnabenefits.com.

CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact leaveadministration@cna.com.

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