Claims Quality Assurance & Risk Analyst

Pacific Asset Management, LLC; Omaha (NE); On-site; USD 91,693,056 - 123,212,544; Full time

Job summary

Pacific Life is seeking an Operations Quality Assurance Specialist to join our Consumer Markets Division in Omaha, NE or Charlotte, NC. You will conduct detailed QA audits of claims transactions and deliver actionable insights to improve quality and reduce risk across the organization.

In this role, you’ll partner with claims leaders and processors to clarify expectations, document findings, and support corrective action planning.

Qualifications

• 1–4 years of experience in claims processing, claims quality assurance, auditing, compliance, insurance operations, or operational risk/control environments.
• Strong analytical and critical thinking skills with the ability to identify claim processing patterns, root causes, procedural gaps, and risk trends across QA review results.
• Exceptional attention to detail and documentation accuracy.
• Ability to interpret and apply claims procedures consistently while exercising sound judgment in pay, set-up, and follow-up review scenarios.

Responsibilities

• Perform detailed quality audits of claims transactions across Pay QA, Set-Up QA, and Follow-Up QA, including claim payment accuracy, interest review and calculation.
• Evaluate claims processing for adherence to established procedures, authority guidelines, controls, regulatory requirements, service standards, and customer-focused claim handling expectations.
• Document QA findings for pay, set-up, and follow-up reviews, including defect type, root cause, severity, risk impact, coaching opportunity, and recommended corrective action.
• Partner with claims leaders, processors, trainers, and business partners to clarify expectations, reinforce procedures, and support corrective action planning when quality gaps are identified.
• Analyze QA results to identify trends in payment errors, setup accuracy, missing or incomplete documentation, follow-up timeliness, procedural gaps, and recurring claim handling themes.
• Contribute to claims QA reporting and insight development that helps leadership understand risk areas, training needs, workload impacts, and opportunities to improve claim quality and consistency.
• Support continuous improvement initiatives aimed at increasing quality, efficiency, and consistency.
• Participate in calibration sessions for Pay QA, Set-Up QA, and Follow-Up QA to ensure review accuracy, consistent scoring, and alignment across QA reviewers and claims operations.

Skills

Claims processing

Quality assurance

Auditing

Regulatory compliance

Operational risk

Job description

Pacific Life is seeking an Operations Quality Assurance Specialist to join our Consumer Markets Division in Omaha, NE or Charlotte, NC. You will conduct detailed QA audits of claims transactions and deliver actionable insights to improve quality and reduce risk across the organization.

In this role, you’ll partner with claims leaders and processors to clarify expectations, document findings, and support corrective action planning.