Claims Quality & Compliance Specialist

As a Quality Assurance & Review specialist, you will be responsible for scoring files against quality checklists, documenting errors, trends, and corrective actions. You will conduct root-cause analysis on repeat defects and drive preventive measures to ensure continuous improvement in the claims processing workflow. Your role will also involve ensuring regulatory and policy compliance by monitoring and ensuring all claims decisions and communications align with IRDAI guidelines, company policies, and data privacy norms. You will stay updated on regulatory changes, translate them into updated SOPs, checklists, and training notes, and support internal/external audits to ensure timely closure of observations. In addition, you will design and maintain control points in the claims workflow, validate consistent application of policy terms, exclusions, and sub-limits, and review exception approvals and high-value claims for policy/authority compliance. Monitoring fraud risk, identifying red flags, and escalating suspicious patterns to the fraud investigation team will also be part of your responsibilities. You will play a key role in training, coaching, and change management by providing feedback and coaching to claims processors, conducting refresher sessions on quality standards, documentation norms, and regulatory updates. Collaborating with Ops/Training to update SOPs, checklists, and knowledge repositories will be essential for continuous improvement. Furthermore, you will be involved in reporting and metrics by publishing periodic quality dashboards, tracking CAPA implementation status and effectiveness, and presenting insights and recommendations to management for continuous improvement. Stakeholder coordination with Operations, Compliance, Legal, IT, and Finance to resolve systemic issues and implement fixes will also be a crucial aspect of your role. Participating in process improvement, automation, or digitization initiatives and benchmarking internal quality standards against industry best practices to recommend enhancements will be part of your continuous improvement and projects responsibilities. This is a full-time, entry-level position located in-person. If you are passionate about ensuring quality, compliance, and continuous improvement in claims processing, we encourage you to apply now at btwgroup.co/careers.,