Remote Senior Claims Governance & Compliance Analyst

OpenKrill; United States; Remote; USD 74,000 - 93,000; Full time

Benefits offered by this job

Healthcare coverage

Health savings account (HSA)

Paid parental leave

Retirement savings plan

Paid time off

Employee wellbeing programs

Professional development opportunities

Job summary

OpenKrill is seeking a Carrier Senior Claims Oversight Analyst in the United States. The role strengthens claims governance, ensures regulatory compliance, and improves operational performance across delegated claims operations, collaborating with TPAs and internal teams to drive accurate decisions.

You will analyze complex claims, interpret coverage, support audits, and develop governance standards, with a focus on data-driven improvement and risk management in a fully remote setup.

Qualifications

• Minimum 5 years in insurance claims, claims ops, compliance, QA, or related field.
• Strong knowledge of claims handling, coverage interpretation, and regulatory requirements.
• Experience overseeing TPAs, audits, and regulatory inquiries.

Responsibilities

• Review high-value, complex, and over-authority claims with recommendations aligned to carrier guidelines.
• Evaluate coverage determinations, appeals, exceptions, and escalated claims with documented support.
• Oversee delegated claims operations by TPAs, ensuring compliance with procedures and regulations.
• Identify trends, weaknesses, compliance concerns, and opportunities to improve quality and efficiency.
• Support audits, market conduct examinations, regulatory inquiries, and corrective actions.
• Assist with fraud investigations, reporting, risk assessments, and mitigation strategies.
• Analyze claims data, audit results, performance metrics to identify patterns and improvements.
• Develop and update claims handling guidelines, governance standards, and procedures.

Skills

Claims governance

Regulatory compliance

Data analysis

Audits & examinations

Stakeholder management

Communication

Problem solving

Independent work

Education

Bachelor's degree in Business

Bachelor's degree in Insurance

Bachelor's degree in Risk Management

Job description

OpenKrill is seeking a Carrier Senior Claims Oversight Analyst in the United States. The role strengthens claims governance, ensures regulatory compliance, and improves operational performance across delegated claims operations, collaborating with TPAs and internal teams to drive accurate decisions.

You will analyze complex claims, interpret coverage, support audits, and develop governance standards, with a focus on data-driven improvement and risk management in a fully remote setup.