[Hiring] Senior Claims Quality Assurance Auditor @Pie Insurance

Role Description

The Senior 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
  • Conduct regular 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 established audit methodologies and sampling techniques to ensure comprehensive evaluations
• Documentation & Reporting
  • Document 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 best practices that impact claims quality
• Training & Knowledge Sharing
  • Train staff on quality assurance policies, procedures, and industry best practices
  • Provide coaching and guidance to adjusters on claim handling techniques and compliance requirements
  • Conduct training sessions on common audit findings and remediation strategies
  • Share knowledge of regulatory requirements and Claims Best Practices with Claims teams
  • Support Claims Learning & Development initiatives with quality-focused training content
• Cross-Functional Collaboration
  • Partner with Claims Adjudication team to address quality issues and implement improvements
  • Work with Claims Regulatory Compliance team to ensure audits capture all compliance requirements
  • Collaborate with Claims Learning & Development team to develop targeted training based on audit findings
  • Coordinate with Claims Data & Analytics team to support quality reporting and trend analysis
  • Communicate with Claims leadership on quality trends and recommended actions

Qualifications

• High School diploma or GED required; Bachelor's degree in Business Administration, Risk Management, or related field preferred
• 8+ years of workers' compensation claims experience with strong understanding of claim handling practices
• 3+ years of experience in claims auditing, quality assurance, or compliance roles preferred
• Minimum of 2 years of California workers' compensation claims experience required
• Strong knowledge of Claims Best Practices and regulatory requirements across multiple jurisdictions
• Experience conducting claim file reviews and documenting audit findings

Requirements

• The use of AI in Application Review: To support a fair, efficient, and consistent hiring process, we use AI-powered tools to assist in the initial screening of applications. These tools help us identify qualifications and prior work experiences that align with the requirements of the role. We may also use AI assistant video tools during interviews to support note-taking and candidate evaluation. All AI-powered outputs are still subject to human oversight and decision-making at multiple stages of the process. By submitting your application, you acknowledge and consent to Pie utilizing these AI technologies to assist in our evaluation process.

Benefits

• Competitive cash compensation
• Comprehensive health plans
• Generous PTO
• Future focused 401k match
• Generous parental and caregiver leave

Location Information

• Unless otherwise specified, this role is remote. Remote team members must live and work in the United States (territories excluded) and have access to reliable, high-speed internet.

Additional Information

• Pie Insurance is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristic.
• Pie Insurance participates in the E-Verify program.
• Pie Insurance is committed to protecting your personal data. Please review our Privacy Policy.
• Safety First: Pie Insurance is committed to your security during the recruitment process. We will never ask you for credit card information or ask you to purchase any equipment during our interview or onboarding process.
• Pie Named to 2025 America's Best Startup Employers
• Pie Insurance 2025 State of Workplace Safety Report