Claims - Quality Assurance Specialist

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

The Quality Assurance Specialist’s primary responsibility is to monitor and review claims to ensure compliance with MEMIC’s internal best practices, as well as statutory requirements, and to develop and implement strategies to improve compliance in these areas. In addition, this position may be called upon to assist and support the compliance and training staff in the development of compliance plans and training documentation.

Responsibilities:

• Monitors indemnity claim file activity in real time to ensure jurisdictional benchmarks related to timeliness of initial compensability determinations, accuracy of payments and/or denials, and completion of forms over the life of the claim are met.
• Reviews state specific legal orders to ensure timely response, payment and form filings, when applicable.
• Reconciles penalties incurred to confirm validity and provides recommendations to Claim Management on the appropriateness of a payment or an appeal, when applicable.Identifies, analyzes, and summarizes trends in results and works with Claim Management and/or Claim Trainers 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 by utilizing structured review sheets to objectively demonstrate claim handler’s performance.
• 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.

Requirements

• Bachelors Degree is preferred.
• 2-4 years of claim handling experience required; multi-jurisdictional experience preferred, workers compensation experience preferred.
• Strong attention to detail, accuracy, and analytical skills are necessary.
• Excellent interpersonal, written and verbal communication skills are essential.
• Must be organized with effective time management skills to meet strict deadlines, when necessary.
• Must have ability to prioritize and focus.
• Must possess the ability to work effectively in a fluid team environment and self-motivate.
• Proficient in Microsoft Office.

MEMIC is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religious creed, national origin, ancestry, age, disability, genetics, gender identity, veteran's status, sexual orientation, or any other characteristic protected by law. Additionally, we are committed to providing an inclusive and accessible recruitment experience for all candidates. If you need a reasonable accommodation during the interview process, please contact us [e-mail] .

To ensure an equitable and authentic interview process, candidates should not use AI or chatbot tools during the live interview or phone screen. We welcome any preparation you choose to do beforehand, but all responses shared during the interview must be your own.

Note: MEMIC does not offer Stem-OPT EAD Extension for this role.

Targeted salary range: $70-80k