At OneAmerica, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success.
The Quality Consultant is responsible for evaluating the quality of OneAmerica policies, processes, documentation, and adherence as well as provide consultative assistance for analysis and improvements. This individual will support leaders and associates throughout the enterprise. This role adds value to the company by evaluating existing cross-functional processes to identify continuous improvement opportunities and improve quality.
- Collaborate with partners in claims leadership and the training center of excellence to identify and address areas of improvement and training opportunities.
- Collaborate with claims leadership to update, develop and document policies and procedures.
- Conduct comprehensive quality reviews of random claims by reviewing data integrity, financial accuracy, claim outcome, proper documentation, customer service, appropriate use of resources, and execution of appropriate individualized claim file plan in a timely manner.
- Conduct quality reviews based on department agreed upon focused segments
- Review quality/appropriateness resource utilization directs vendor services, and activities on referrals.
- Provide one-on-one feedback of each quality review with the claim staff to ensure a clear understanding of the strengths and/or areas for improvement are understood. Includes future action plan for cases identified where outcome plan should be modified/changed.
- Provide positive and constructive audit result feedback to claims staff and training area including overall and individual trends.
- Provide feedback to assist with performance management by giving objective feedback on performance of key job accountabilities. Conducts focused individual reviews as needed.
- Input/Maintain accurate audit results in database/ spreadsheets as required.
- Maintain working knowledge of all contracts, policies/procedures and account-specific information to accurately assess quality of claims management activities.
- Maintain knowledge of each person’s “referral criteria” to ensure appropriate claims are referred appropriately.
- Maintain a level of participation and commitment to individual, team, Claims organization, policyholder companies, and OA results through continuous communication and identification of improvement areas.
- Provide assistance with training and mentoring of claim staff to assist with increasing staff proficiency levels and addresses trends identified in quality assurance reviews.
- Complete external reinsurance claim file reviews/file pulls and provide feedback through formal report and face-to-face meetings, telephone, etc.
- Conduct Performance Guarantee audits and prepares summary report as outlined in the Policyholder agreement.
- Provide assistance as the business dictates, such as Claim’s Examiner role, Team Leader/Consultant, Supervisor, etc... (Not all inclusive)
- Provide assistance for business projects as needed such as testing for updates to Claims system, etc:
- Four-year college degree or a combination of equivalent related work experience and education.
- Minimum of seven years of experience managing long-term disability claims.
- Minimum requirement of at least a senior status managing long-term disability claims.
- Quality review experience strongly preferred.
- Familiar with MD Guidelines (Reed Group)
- Ability to write executive summaries and reports to external customer’s preferred.
- Mentoring experience preferred.
- Ability to decipher, interpret and apply knowledge of medical data, policy provisions ERISA/state regulations, financial data, risk management practices and other documentation to assess the quality of the claims management activities, provide appropriate conclusion and establish action steps needed.
- Excellent written and oral communication skills.
- Excellent organizational and analytical skills.
- Ability to work independently, make sound judgments and establish good working relationships internally and externally.
- Broad, in-depth knowledge of claim strategies geared toward reemployment outcomes.
- Proven ability to effectively give and receive feedback as well as be an effective listener.
- Proven ability to provide feedback on trend identification and staff training needs.
Salary Band: 05B
Due to the COVID-19 pandemic, the majority of OneAmerica associates are currently working remotely in accordance with our safety protocols. The selected candidate will be expected to temporarily work remotely for an unspecified period of time as determined in OneAmerica’s sole discretion. When normal business operations resume, the selected candidate will be expected to physically return to work in the office located in Portland, ME.
Disclaimer: OneAmerica is an equal opportunity employer and strictly prohibits unlawful discrimination based upon an individual’s race, color, religion, gender, sexual orientation, gender identity/expression, national origin/ancestry, age, mental/physical disability, medical condition, marital status, veteran status, or any other characteristic protected by law.