Senior Compliance and Quality Specialist Assigned Risk remote US
AF Group

Job Info

---

SUMMARY:

Acts as a leader and technical expert to identify and resolve assigned risk compliance issues. Responsible for policy, claims, billing and audit compliance oversight. Reviews and interprets NCCI and state circulars summarizing for management. Proposes changes needed based on changing regulations. Performs compliance audits focusing on state specific statutes, compliance audits of core functions to NCCI/state guidelines, adherence to the Company's standards and practices and financial outcomes. Coordinates and leads onsite and self-audits with NCCI and independent states. Developing and using tools to track and correct issues identified. Builds a consistent view of assigned risk quality through calibration. Key partner in action plan development with accountability for action plan completion. Central point of contact with internal stakeholders. In addition, this position will articulate business challenges and requests in technology terms and the development of business cases to convert requests/recommendations to deliverable solutions for both compliance and automation initiatives. This role will be responsible for the development of business cases (both simple and complex), management of projects, testing and post implementation oversight.

RESPONSIBILITIES/TASKS:

Compliance and Quality Specialist

• Perform audits as assigned including but not limited to audit, billing claims and policy quality assessments which may require calibration, risk assessments, reserve oversight, compliance focused state specific audits, and compliance audits of core functions with high regulatory oversight.
• Draft audit reports, maintain audit schedules, and collaborate with stakeholders to develop plans of action and ensure execution and completion of action items.
• Drive execution and resolution of identified compliance issues including but not limited to developing and directing plans for response to state and federal rules and regulations that impact the Company. Analyzes data for stakeholders and present analysis in a format appropriate for strategic discussion.
• Enterprise technical expert responsible for researching, monitoring and making recommendations including but not limited to state and federal rules and regulations, industry & the Company benchmarks, complex automation efforts, and the Company standards and practices.
• Timely review and interpretation of state and NCCI circulars to management. Proposes changes to systems and processes based on circulars. Ensures circulars are addressed timely and accurately.
• Coordinates and collaborated with leads both onsite and self-audits for NCCI and independent state audits. Develops and maintains tracking system by attribute, research issues and provides recommendations for management and ensures timely response.
• Based on user and audit identifies issues, proposes solutions, gathers requirements and ensures accurate implementation of needed changes.
• Acts as a resource, subject matter expert, and single point of contact for the business and application development teams. Collaborate with the IT team to ensure traceability between defined test cases and elicited testing, effective hand off of requirements and identification of defects.
• Build, audit and report on self monitoring activities including but not limited to the effectiveness of the Company compliance with state and federal rules, adherence to handling of insurance department consumer complaints, penalty resolutions and authorities, and compliance with state reporting bureau data.
• Audit enterprise standards and practices for handling of state and other claim audits..
• Build and maintain a compliance library and an historical tracking of regulatory activity and handling changes that includes a description, impact to the Company statement, and action taken to track and report on all activity.
• Builds relationships with key business unit (internal and external) resources to gain understanding of overall business unit direction and influence execution.
• Performs ad-hoc projects, research, and analysis in support of key stakeholders.

Additional Senior Compliance and Quality Specialist Responsibilities/Tasks:

• Drives execution and resolution of complex, multifaceted compliance issues.
• Functions as a team facilitator/ leader within multi-functional teams.
• Provides work direction to other professionals and support staff.
• Makes critical contributions to managing and solving complex and/or large scale business challenges.
• Independently performs assignments with instructions limited to results expected.
• Granted decision making authority regarding quality and compliance issues as designated by management.
• Responsible for designing and developing reports/scorecards with minimal management oversight.
• Manages projects to completion as assigned by the manager.
• Act as a management proxy in meetings etc.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor's degree in insurance, business or a related field. Progress towards or completion of, industry-recognized professional designations preferred. Combinations of relevant education and experience many be considered in lieu of a degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.

Additional Education for Senior Compliance & Quality Specialist:

Bachelor's degree in insurance, business or a related field. Master's or advanced degree work preferred. Progress towards or completion of, industry-recognized professional designations preferred. Combinations of relevant education and experience many be considered in lieu of a degree

EXPERIENCE:

Compliance and Quality Specialist

Five years in a workers compensation company or compliance environment. Demonstrated technical knowledge in three or more of the following areas: compliance research and oversight, claim case management, underwriting, loss prevention, auditing, vendor management, NCCI or similar knowledge that provides the necessary skills, knowledge and abilities. Multi-state experience or compliance knowledge preferred.

Senior Assigned Risk Compliance and Quality Specialist

Eight years of progressive responsibility in a workers compensation or compliance environment. Demonstrated technical knowledge in all the following areas: compliance process for new state entry, compliance and/or claims/reserve oversight, action planning and execution of complex compliance issues, system changes/implementations. Two years in supervision, or a lead/senior role demonstrating leadership skills. Multi-state experience required.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Ability to exercise sound, consistent judgment in evaluating and recommending compliance and handling action.
• Ability to read, interpret and understand contract language.
• Knowledge of ability to analyze and interpret WC law, federal and state rules and regulations as it relates to claims, jurisdiction and compliance. Excellent oral and written communication skills.
• Excellent analytical skills to identify improvement opportunities, develop solutions and assess impact.
• Ability to interact with all levels of internal staff and management, and effectively exchange information clearly and concisely, present ideas, report facts and other information, as well as, respond to questions as appropriate.
• Strong interpersonal skills with well-developed conflict management/negotiation and presentation skills.

Additional skills/knowledge abilities (SKA) required for the Senior Compliance & Quality Specialist

• Demonstrated ability to drive execution and resolution of complex, multifaceted issues.
• Knowledge of industry trends and compliance environment in multiple states.
• Advanced conflict management/negotiation/presentation skills.
• Comprehensive professional and business knowledge with multiple areas of expertise.
• Ability to create unprecedented and innovated solutions to complex problems.
• Recognized as a technically credible role model
• Mentors and coaches others with less experience.
• Demonstrated ability to resolve and collaborate on complex, multifaceted compliance issues.
• Demonstrated leadership ability with proven results as a team facilitator/ leader within multi-functional teams.

WORKING CONDITIONS:

Work is performed in a home office or corporate office environment with minimal hazards. Travel as required.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.

This job has expired.