Skills & Competencies for Claims Quality Auditor I

Claims Quality Auditor I job profile

Book a Demo and Receive a Sample Job Profile

JOB SUMMARY for Claims Quality Auditor I

Audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures.

JOB RESPONSIBILITIES for Claims Quality Auditor I

Selects claims through random processes and/or other criteria. Makes recommendations to improve quality, workflow processes, policies and procedures.

Claims Quality Auditor I SALARY RANGE

BASE 50%
$49,663
TOTAL 50%
$51,110
Job Level
P02
Job Code
HC07000626
Education/Degree
Associate's Degree
Reports To
Supervisor or Manager

Claims Quality Auditor I Skills and Competencies List

Proficiency Levels and Behavioural Indicators
Salary.com identifies five increasing levels of proficiency for each skill/competency. Some jobs require only a relatively low level of proficiency in each skill/competency, while other jobs will require a more advanced level of proficiency in the same skill/competency. These levels rate the degree of proficiency (skill level, expertise) we expect the incumbent to perform in the given skill/competency for the given job. Note that we intentionally do not associate timeframes or years of experience in performing the skill/competency because that can be misleading. Proficiency levels identify what the incumbent knows and can do rather than how long they have been doing it. Also, note that the proficiency levels are cumulative, e.g., a level 4 proficiency implies the ability to perform all the behaviors at the lower levels.
Check each Claims Quality Auditor I skill and competencie below to view definitions.
INDUSTRY COMPETENCIES JOB FAMILY COMPETENCIES CORE COMPETENCIES
BOOK A DEMO

7 hard skills or competencies (industry competencies) for Claims Quality Auditor I

1 Industry Competency – Insurance Industry
Proficiency Level -2
Skill definition-Applying knowledge of the insurance industry to provide risk management services and protection to various individuals from financial loss.
Level 1 Behaviors
(General Familiarity)
Cites different types of insurance policies and describes the advantages and disadvantages of each.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Compiles insurance quotes based on customer information and rates for insurance policies.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Examines insurance applications and letters from clients to determine necessary policy changes.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Evaluates existing claims handling process to identify fraud and opportunities for optimization of outcomes.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Champions the adoption of AI and automation technologies to streamline insurance operations.
See 4 More Skill Behaviors
2 Industry Competency – Insurance Legal and Regulatory Environment
Proficiency Level -2
Skill definition-Creating, executing, and adhering to state and federal laws governing insurance operations to ensure financial security and consumer protection.
Level 1 Behaviors
(General Familiarity)
Cites examples of the legal principles of insurance applicable to multiple types of insurance products.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Assists in assessing regulatory risks to ensure insurance operations meet compliance and regulatory obligations.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Adopts legal and regulatory initiatives to assess possible risks and maintain insurance solvency.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Directs the regulation of insurance products to ensure insurance policy provisions comply with state laws.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Builds policy and regulatory tools to monitor and assess compliance levels with insurance laws and regulations.
See 4 More Skill Behaviors
3 Claims Quality Auditor I - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor I
Proficiency Level - 4
5 Competency for - Claims Quality Auditor I
Proficiency Level - 5

2 general skills or competencies (Job family competencies) for Claims Quality Auditor I

1 Job Family Competencies – Quality Assurance
Proficiency Level -1
Skill definition-Verifying the adherence of product with required specifications and expectations to track and resolve deficiencies prior to product release.
Level 1 Behaviors
(General Familiarity)
Explains the step-by-step process of developing quality assurance plans.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Conducts quality assurance reviews related to surveys, licensing, and complaint investigations.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Manages the training of personnel in the correct interpretation of quality assurance protocols and processes.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Manages the refinement, management, and continuous growth of quality assurance capabilities.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Establishes quality assurance program by developing and managing processes to identify and mitigate risks.
See 4 More Skill Behaviors
2 Job Family Competencies – Quality Audit
Proficiency Level -2
Skill definition-Examining the conformance of a quality system to comply with standard specifications or procedures of the product, design, process, and system.
Level 1 Behaviors
(General Familiarity)
Identifies the basic quality audit functions and processes.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Conducts quality audits of the computerized maintenance tracking program to ensure accurate data entry updates.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Maintains evidence of quality conformance and ensures availability available for external audits.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Directs full-scope reviews of audit engagements to comply with internal audit methodology and quality standards.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Conceptualizes quality management system (QMS) audit process to drive internal procedure and standard conformance.
See 4 More Skill Behaviors
3 Claims Quality Auditor I - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor I
Proficiency Level - 4
5 Competency for - Claims Quality Auditor I
Proficiency Level - 5

8 soft skills or competencies (core competencies) for Claims Quality Auditor I

1 Core Competencies – Standard Operating Procedures (SOP)
Proficiency Level -2
Skill definition-A set of written instructions that describes the step-by-step activities to complete tasks in compliance with business standards and industry regulations.
Level 1 Behaviors
(General Familiarity)
Discusses the considerations and concerns on applying SOP for the first time.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Documents the SOP drafts and outlines for final approval.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Initiates SOP revisions to support continuous improvement of processes.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Evaluates the benefits and drawbacks of a specific SOP; oversees the corresponding enhancements.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Establishes formal policies and procedures to guide the our SOP practices.
See 4 More Skill Behaviors
2 Core Competencies – Attention to Detail
Proficiency Level -2
Skill definition-Executing and completing a task with a high level of accuracy.
Level 1 Behaviors
(General Familiarity)
Identifies the procedures for making sure that results are mistake-free.
See 4 More Skill Behaviors
Level 2 Behaviors
(Light Experience)
Processes limited amounts of detailed information with reasonable accuracy.
See 4 More Skill Behaviors
Level 3 Behaviors
(Moderate Experience)
Reviews and analyzes the accuracy of data and details.
See 4 More Skill Behaviors
Level 4 Behaviors
(Extensive Experience)
Designs systems to help the team organize and track details and project progress.
See 4 More Skill Behaviors
Level 5 Behaviors
(Mastery)
Develops best practices for identifying and correcting errors, oversights, and omissions.
See 4 More Skill Behaviors
3 Claims Quality Auditor I - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor I
Proficiency Level - 4
5 Competency for - Claims Quality Auditor I
Proficiency Level - 5

Summary of Claims Quality Auditor I skills and competencies

There are 7 hard skills for Claims Quality Auditor I, Insurance Industry, Insurance Legal and Regulatory Environment, Insurance Products, etc.
2 general skills for Claims Quality Auditor I, Quality Assurance, Quality Audit.
8 soft skills for Claims Quality Auditor I, Standard Operating Procedures (SOP), Attention to Detail, Honesty And Integrity, etc.
While the list totals 17 distinct skills, it's important to note that not all are required to be mastered to the same degree. Some skills may only need a basic understanding, whereas others demand a higher level of expertise.
For instance, as a Claims Quality Auditor I, he or she needs to be proficient in Standard Operating Procedures (SOP), be proficient in Attention to Detail, and be proficient in Honesty And Integrity.

It's Easy to Get Started

Get the precision you need to assess, hire, and develop top talent with skills and competencies – see how with a personalized demo.