Claims QA Specialist - Compliance & Process Improvement

MEMIC; Portland (ME); On-site; USD 70,000 - 80,000; Full time

Job summary

MEMIC in Portland, ME is seeking a Quality Assurance Specialist to monitor and review claims for compliance with internal standards and statutory requirements, and to develop strategies to improve accuracy and outcomes. The role supports the compliance and training staff, reviews indemnity files in real time, and collaborates with Claim Management to address trends, penalties, and form filings.

Candidates should have a bachelor's degree (preferred) and 2–4 years of claim handling experience,

Qualifications

• 2-4 years of claim handling experience, multi-jurisdictional experience preferred.
• Workers' compensation experience preferred.
• Strong attention to detail, accuracy, and analytical skills.
• Excellent interpersonal, written and verbal communication skills.

Responsibilities

• Monitors indemnity claim file activity in real time to meet timeliness benchmarks related to initial compensability determinations, payments/denials, and form completion.
• Reviews state specific legal orders to ensure timely response, payment and form filings, when applicable.
• Identifies, analyzes, and summarizes trends in results and works with Claim Management to develop a plan to enhance quality and performance.
• Completes objections of fee reviews in applicable jurisdictions, follows for and tracks response.
• Completes state reconciliation in applicable jurisdictions. Retroactively reviews selected indemnity claim files from a compliance perspective and summarizes results.
• Assists Compliance Associate with mandatory Medicare reporting data integrity as needed.
• Assists with quality reviews of Compliance Assistants as needed.
• Supports compliance team goals by assisting with special projects or tasks as directed by Manager, Claim Compliance.

Skills

Attention to detail

Analytical skills

Communication skills

Time management

Teamwork

Education

Bachelor's degree preferred

Tools

Microsoft Office

Job description

MEMIC in Portland, ME is seeking a Quality Assurance Specialist to monitor and review claims for compliance with internal standards and statutory requirements, and to develop strategies to improve accuracy and outcomes. The role supports the compliance and training staff, reviews indemnity files in real time, and collaborates with Claim Management to address trends, penalties, and form filings.

Candidates should have a bachelor's degree (preferred) and 2–4 years of claim handling experience,