Job Summary
This position will work closes with CNA's third party administrator that handles Long-Term Care claims and will review completed files/claims to evaluate compliance, controls, customer service and ensures adherence to Claims Best Practices; consistency, timeliness, and accuracy of benefit eligibility decisions. In addition to specific claim reviews this position will also be responsible for identifying process improvements to the claims process, outcomes and customer satisfaction making recommendations to senior leadership and participating in the implementation of approved changes.
Essential Duties & Responsibilities
Performs a combination of duties in accordance with departmental guidelines:

1. Conduct Quality Assurance post-decision audits of insurance claims, in accordance with established strategies and objectives, focusing on:

• Decision accuracy consistency and timeliness
• Risk mitigation
• Adherence to guidelines and operating procedures
• Alignment with best practices

1. Supports senior leadership in the identification of claim trends and opportunities for continuous process improvement. Conducts pre-review of Claim decisions which may include high dollar claim payments and proposed denials.
2. Participate as needed in response to insured decision appeals, escalations, and complaints. Drafts guidelines and implements changes to business processes, workflows, and practices to ensure alignment with CNA expectations.
3. Review regulatory changes and identify impact to operations.
4. Supports market conduct exams and DOI audits.
5. Supports local training needs in conjunction with overall Claim objectives; facilitate and conduct common training as needed.
6. Review Claim reports and dashboards.
7. Participates with senior leadership in the development and implementation of Claim policies, business strategies, metrics and goals; regularly evaluates performance against goals, and holds self-accountable for achieving desired results.
8. May perform additional duties as assigned.

Reporting Relationship
Typically Manager or above
Skills, Knowledge & Abilities

1. Working knowledge of claim auditing and assigned line of business. Has the ability to analyze, interpret, and present complex problems and solutions to a variety of audiences.
2. Ability to effectively interact and collaborate with all levels of CNA's internal and external business partners, possessing strong communication and presentation skills.
3. Strong analytical, critical thinking and problem solving skills, with the ability to effectively plan and manage multiple projects and project work teams with an eye for Claim innovation.
4. Ability to identify Claim opportunities, evaluate options, and recommend optimal solutions.
5. Prioritizes Claim opportunities and achieves results by taking a proactive, long−term view of business goals and objectives.
6. Ability to understand business needs and think through all scenarios and challenges before formulating potential solutions.
7. Ability to solve problems with a sense of urgency; able to utilize and manage all available resources to make informed decisions and achieve superior results.
8. Demonstrates the knowledge and understanding of when and how to use Claim data and metrics to assist in making informed business decisions.
9. Exercises professional judgment and assumes responsibility for decisions that impact people and quality of service.
10. Ability to creatively and effectively manage through ambiguous and challenging business problems and lead through change while taking appropriate level of risk.
11. Knowledge of Microsoft Office Suite and other business-related software systems, including processing systems and applications.

Education & Experience

1. Bachelor's Degree or equivalent work experience
2. Typically a minimum of three years of related work experience.
3. Knowledge of insurance claim processing preferred, Long-Term Care a plus.