Claims Quality Assurance Auditor

Pie Insurance

2d•$75,000 - $95,000•Remote

About The Position

Pie's mission is to empower small businesses to thrive by making commercial insurance affordable and as easy as pie. We leverage technology to transform how small businesses buy and experience commercial insurance. Like our small business customers, we are a diverse team of builders, dreamers, and entrepreneurs who are driven by core values and operating principles that guide every decision we make. The Claims Quality Assurance Auditor will conduct regular audits and assessments of Pie's claims handling processes to ensure adherence to Claims Best Practices, regulatory standards, and internal guidelines. This role is responsible for reviewing claim files for compliance, identifying areas of non-compliance, and recommending corrective actions to improve claims quality. The auditor will collaborate with Claims teams, prepare detailed audit reports, and support the development of quality control policies and training programs that drive continuous improvement in claims performance and ensure regulatory compliance.

Requirements

High School diploma or GED required; Bachelor's degree in Business Administration, Risk Management, or related field preferred
5+ years of workers' compensation claims experience with strong understanding of claim handling practices
2+ years of experience in claims auditing, quality assurance, or compliance roles preferred
Strong knowledge of Claims Best Practices and regulatory requirements across multiple jurisdictions
Experience conducting claim file reviews and documenting audit findings

Responsibilities

Claims Audit & Assessment:
Collaborate with Claims leadership to design, refine, and continuously improve the quarterly audit program and scoring methodology, ensuring alignment with operational realities while maintaining regulatory defensibility.
Partner with Claims to define:
Weighted scoring criteria
High-risk violation thresholds
File sampling strategy
Performance benchmarks tied to ≥95% compliance targets
Ensure the audit program reflects evolving statutory requirements, regulator audit trends, and internal risk drivers.
Conduct regular monthly and quarterly audits and assessments of quality management systems and claims handling processes
Review claim files to verify compliance with regulatory standards, statutory requirements, and internal guidelines
Evaluate claims for adherence to Pie's Claims Best Practices and quality standards
Assess claim documentation, investigation techniques, reserve adequacy, and settlement practices
Identify areas of non-compliance and recommend corrective actions to address deficiencies
Apply weighted scoring methodology to measure compliance performance and identify systemic risk patterns.
Apply established audit methodologies and sampling techniques to ensure comprehensive evaluations
Documentation & Reporting:
Document monthly and quarterly audit findings with clear, detailed explanations of deficiencies and best practices observed
Prepare comprehensive audit reports for management that include findings, recommendations, and action items
Analyze data to identify trends, patterns, and areas for improvement across the claims organization
Provide timely feedback to adjusters and Claims leadership on audit results
Maintain accurate records of all audits, findings, and corrective action plans
Quality Control & Process Development:
Collaborate with various departments to ensure quality standards are met consistently
Develop and update quality control policies and procedures based on audit findings and regulatory changes
Assist in developing quality assurance goals and objectives aligned with department strategies
Recommend process improvements to enhance claims quality and operational efficiency
Support the implementation of new quality standards and best practices
Compliance & Corrective Action Monitoring
Monitor the implementation and effectiveness of corrective and preventive actions
Track remediation efforts to ensure deficiencies are addressed in a timely manner
Verify that corrective actions result in sustained improvements in claims quality
Coordinate with external auditors and facilitate external audit processes when needed
Stay current with regulatory changes and industry best practices that impact claims quality
Training & Knowledge Sharing:
Train staff on quality assurance policies, procedures, and industry best practices
Provide coaching and guidance to adjusters on claim handling techniques and compliance requirements
Conduct training sessions on common audit findings and remediation strategies
Share knowledge of regulatory requirements and Claims Best Practices with Claims teams
Support Claims Learning & Development initiatives with quality-focused training content
Cross-Functional Collaboration:
Partner with Claims Adjudication team to address quality issues and implement improvements
Work with Claims Regulatory Compliance team to ensure audits capture all compliance requirements
Collaborate with Claims Learning & Development team to develop targeted training based on audit findings
Coordinate with Claims Data & Analytics team to support quality reporting and trend analysis
Communicate with Claims leadership on quality trends and recommended actions