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.

How You’ll Do It

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