Quality Assurance, Risk Control & Special Investigations Analyst

ABOUT THE ROLE

The Quality Assurance, Risk Control & Special Investigations Analyst is a specialized and critical role responsible for ensuring operational integrity, service excellence, and adherence to regulatory standards across our life insurance Third-Party Administrator (TPA) operations. This individual performs three key functions: auditing call and service interactions, conducting pre-referral fraud investigations while providing supporting documentation regarding alleged fraud inquiries, and monitoring internal controls to drive process improvement and mitigate risk.

This role reports directly to the Customer Experience Manager and is open to hybrid in our Dallas office or Remote (US). #LIREMOTE

WHAT YOU’LL DO

• Interaction Auditing: Conduct comprehensive quality audits of inbound and outbound call center interactions, ensuring accuracy, regulatory compliance, and adherence to TPA standard operating procedures.
• Form Review: Review and audit completed service and administrative forms (e.g., policy changes, beneficiary updates) for completeness, accuracy, and proper processing workflow.
• Feedback & Coaching: Deliver timely, objective, and constructive feedback and coaching to call center agents and team leads to improve service quality and transaction accuracy.
• Reporting: Track, analyze, and report on key TPA and QA metrics and trends, identifying root causes of errors and compliance gaps.

• Pre-Referral Case Review: Act as the initial point of contact for internal fraud referrals (SIU). Review and analyze cases flagged for potential fraudulent activity, including claims, policy changes, and applications.
• Evidence Gathering: Collect, organize, and summarize documentation and system history related to suspicious cases.
• Triage & Escalation: Conduct preliminary analysis to determine the validity of the fraud concern. Prepare and present well-documented case files for formal referral to the insurance carrier’s Special Investigations Unit (SIU).
• Documentation: Maintain detailed and confidential records of all investigation activities and findings in accordance with internal protocol and regulatory requirements.

• Control Monitoring: Execute periodic and event-based monitoring of defined key operational and financial controls within the TPA processing environment to confirm effectiveness.
• Risk Reporting: Assist in the reporting of control gaps, deficiencies, and emerging risks to the Risk and Compliance leadership.
• Process Improvement: Collaborate with Operations and Training teams to develop and implement targeted process changes, control enhancements, and improved documentation to mitigate identified risks.
• Training Support: Assist in the development and delivery of training modules related to compliance, fraud awareness, and new quality standards for operations, quality assurance and TPA contact center staff.

WHO YOU ARE

• Minimum of 2 years of professional experience in Quality Assurance (QA) , Compliance, Fraud Analysis, or an operational role within the life insurance, financial services, or TPA industry.
• Strong working knowledge of life insurance policy lifecycle, administrative forms, and general TPA operating procedures.
• Proven ability to analyze complex transaction histories, identify unusual patterns, and draw sound conclusions for risk and fraud assessment.
• Exceptional verbal and written communication skills, with the ability to deliver difficult feedback constructively and concisely summarize investigation findings for executive review.

• Experience with a formal quality monitoring system (e.g., call recording, QA software) preferred
• Familiarity with state and federal regulations governing life insurance (e.g., anti-money laundering, privacy) preferred
• Experience in conducting internal control audits ( SOX, SOC ) preferred
• Experience creating quality assurance checklists within QA systems preferred