CLAIMS AUDITOR

Position Overview

The Claims Auditor supports the internal claims audit program by reviewing claim files to ensure compliance with company guidelines, regulatory requirements, and industry best practices. The role evaluates the accuracy, quality, and timeliness of claim handling; identifies deficiencies; documents findings; and recommends improvements. The Claims Auditor works closely with the Claims Audit Manager and Claims Leadership to enhance operational effectiveness and maintain consistent, compliant claims practices.

Key Responsibilities

• Conduct audits of claim files to assess adherence to internal policies, state regulations, and claims handling standards.
• Evaluate coverage analysis, investigations, documentation, reserving, and settlement activities for accuracy and completeness.
• Identify procedural gaps, compliance risks, and opportunities for operational improvement.
• Prepare detailed audit reports and clearly communicate findings to claims leadership.
• Analyze audit trends to support performance improvement initiatives and recommend corrective actions.
• Participate in internal and external audit activities, including DOI and reinsurer reviews.
• Maintain accurate audit documentation and ensure adherence to retention requirements.
• Support audit planning, scheduling, file selection, and quality monitoring.
• Contribute to training and continuous improvement efforts based on audit outcomes.

Integrated Competencies:

• Applies strong technical knowledge of claims practices, insurance regulations, and company standards.
• Demonstrates analytical capability to evaluate complex files and identify trends and risks.
• Communicates clearly and professionally while maintaining positive working relationships.
• Upholds confidentiality, integrity, and consistent adherence to audit and regulatory standards.
• Engages in ongoing professional development and supports improvement of claim-handling quality.
• Proficiency with Microsoft 365 (Teams, Word, Excel, PowerPoint, Outlook).
• Familiarity with claims systems such as Guidewire, Xactimate, or other industry tools.

Qualifications

• Bachelor’s degree in business, insurance, risk management, or related field preferred.
• 5 years of P&C claims handling, quality assurance, or claims auditing experience.
• Experience with property and liability claims, including CAT work, preferred.
• Strong knowledge of policy interpretation, coverage analysis, and claims best practices.
• Proficiency with claims management systems and audit tools.