Claims Operation Specialist

Nassau County, NY - Hybrid after 90 days, 3 days in 2 days remote Responsibilities: Collaborate with different departmental and team leaders to make sure that every facet of our operations complies with both relevant regulatory standards and industry best practices. In the planning team, you will coordinate with various departmental and team leaders to confirm that all aspects of our operations align with applicable regulatory standards and industry best practices. Oversee and carry out audits on claim issues before and after payment to guarantee accuracy in financial, processing, and operational matters. Ensure that the adjudication of claims is consistent with policy terms, standard operating procedures (SOPs), and both state and federal regulations. Investigate the root causes of errors, overpayments, or underpayments to avoid future occurrences. Review current policies, SOPs, and guidelines to maintain their relevance, accuracy, and adherence to current laws and industry standards. Actively suggest updates to policies, SOPs, and guidelines based on findings from audits and evolving legal requirements. Manage the necessary claims operational setup and compliance frameworks needed for business expansion into new states. Evaluate workflows and outcomes in the claims department to help develop key performance indicators (KPIs) and assessment metrics. Assist with month-end closing processes and deliver statistical data analysis. Engage in system development, maintenance, and support activities, with the possibility of overseeing these tasks, while working collaboratively with external vendors. Requirements and Skills: Five to seven or more years of extensive experience in property and casualty (P&C) claims, combined with a thorough understanding of the industry. Demonstrated experience in roles emphasizing claims auditing, quality assurance, or compliance, with responsibilities including management or auditing tasks. Solid grasp of both state and federal insurance regulations, Fair Claims Settlement Practices, and compliance necessities (for example, Medicare Secondary Payer/Section 111 Reporting). Familiarity with the operational framework and compliance needed for entering new jurisdictions. Proven ability to investigate the root causes of errors proactively and suggest strategic improvements for quality enhancement. Skills in financial data analysis are essential. Experience working with IT departments and external vendors on developing systems, maintaining them, or improving processes is important. Strong capabilities in written and verbal communication, organization, critical thinking, and analysis. A bachelor’s degree in Business, Finance, Computer Science, Statistics, or a comparable field is preferred. Familiarity with SAP, Power BI, SQL, Python, R, Tableau, Excel, and/or data cleansing is an advantage. Professional insurance credentials (such as CPCU, AIC) are very desirable. Certification from the International Compliance Association or a similar recognized compliance organization is beneficial. Being bilingual in Korean is an added advantage. #J-18808-Ljbffr CWA Recruiting