Manage and conduct pre
and post-payment adjudication audits on claim matters to ensure financial, processing, and operational accuracy
Verify that claim adjudication aligns with policy terms, standard operating procedures (SOPs), and state or federal regulations
Investigate the underlying causes of errors, overpayments, or underpayments to prevent future recurrence
Conduct reviews of existing policies, SOPs, and guidelines to ensure relevance, accuracy, and compliance with current laws and industry standards
Proactively propose updates to policies, SOPs, and guidelines based on audit findings and changing legal requirements
Handle claims operational setup and compliance frameworks required for business expansion into new states
Assess claim departmental workflows and results to assist with the development of key performance indicators (KPIs) and evaluation metrics
Support month-end closings and provide statistical data analysis
Participate in, with the potential to oversee, system development, maintenance, and support, while collaborating with and managing external vendors
Ad-hoc projects and other responsibilities as assigned

5–7+ years of progressive experience in property and casualty (P&C) claims, with deep industry knowledge and understanding
Proven experience in a claims auditing, quality assurance, or compliance-focused role, including experience managing or auditing
Strong knowledge of state and federal insurance regulations, Fair Claims Settlement Practices, and compliance requirements (including Medicare Secondary Payer/Section 111 Reporting)
Knowledge of operational setup and compliance required for expansion into new jurisdictions
Demonstrated ability to proactively investigate root causes of errors and propose strategic solutions for quality improvement
Proficiency in financial data analysis
Experience collaborating with IT teams and external vendors on system development, maintenance, or process improvement
Strong written and verbal communication, organization skills, critical thinking, and analytical capabilities
Bachelor’s degree in Business, Finance, Computer Science, Statistics, or a related field is preferred
Proficiency in SAP, Power BI, SQL, Python, R, Tableau, Excel, and/or data cleaning is preferred
Professional insurance designations (e.g., CPCU, AIC) are highly desirable
Certification from the International Compliance Association or another recognized compliance group is a plus
Bilingual in Korean is a plus

Medical (PPO), dental (PPO), vision (PPO), and life insurance covered 100% by the company and 50% for dependents
Paid time off and sick leave
13 annual paid holidays
401(k) plan with up to 4% company match
Flexible Spending Account (FSA) & Dependent Care FSA
Quarterly Fringe Benefit reimbursements
Job-related training reimbursement
Casual dress code

Claims Operations Specialist

Key skills