Skills & Competencies for Claims Quality Auditor II

Claims Quality Auditor II job profile

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JOB SUMMARY for Claims Quality Auditor II

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

JOB RESPONSIBILITIES for Claims Quality Auditor II

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

Claims Quality Auditor II SALARY RANGE

BASE 50%
$56,783
TOTAL 50%
$58,355
Job Level
P03
Job Code
HC07000627
Education/Degree
Associate's Degree
Reports To
Supervisor or Manager

Claims Quality Auditor II 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 II skill and competencie below to view definitions.
INDUSTRY COMPETENCIES JOB FAMILY COMPETENCIES CORE COMPETENCIES
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7 hard skills or competencies (industry competencies) for Claims Quality Auditor II

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)
Identifies the key legislation and regulations governing insurance contracts.
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Level 2 Behaviors
(Light Experience)
Records and maintains insurance policy and claims information in a database system.
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Level 3 Behaviors
(Moderate Experience)
Verifies received insurance coverage and damage reports to ensure accurate processing of claims.
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Level 4 Behaviors
(Extensive Experience)
Provides technical guidance to staff on claim investigation to ensure accurate insurance claims processing.
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Level 5 Behaviors
(Mastery)
Pursues creative initiatives that may differentiate our business and give us a competitive advantage.
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2 Industry Competency – Insurance Legal and Regulatory Environment
Proficiency Level -3
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)
Explains the application of insurance regulatory laws to avoid civil penalties and license suspension.
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Level 2 Behaviors
(Light Experience)
Supports the execution of a legal and regulatory framework to promote strict insurance compliance.
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Level 3 Behaviors
(Moderate Experience)
Performs compliance reviews to determine possible violations and deficiencies in insurance regulations.
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Level 4 Behaviors
(Extensive Experience)
Trains teams on new laws and regulations to reduce liability risks and compliance violations.
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Level 5 Behaviors
(Mastery)
Establishes best practices in creating insurance laws and regulations to prevent frauds and malpractices.
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3 Claims Quality Auditor II - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor II
Proficiency Level - 4
5 Competency for - Claims Quality Auditor II
Proficiency Level - 5

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

1 Job Family Competencies – Quality Assurance
Proficiency Level -2
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)
Lists the methods involved in documenting obtained data during quality assurance activities.
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Level 2 Behaviors
(Light Experience)
Supports the quality assurance team in implementing quality assurance systems.
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Level 3 Behaviors
(Moderate Experience)
Partners with internal and external stakeholders to develop data quality assurance plans.
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Level 4 Behaviors
(Extensive Experience)
Provides recommendations on long-term improvements of the company-wide quality assurance process.
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Level 5 Behaviors
(Mastery)
Monitors compliance of all projects with quality assurance guidelines.
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2 Job Family Competencies – Quality Audit
Proficiency Level -3
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)
Locates the appropriate quality tool for documenting audit findings.
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Level 2 Behaviors
(Light Experience)
Supports prospective and retrospective audits to monitor quality and compliance.
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Level 3 Behaviors
(Moderate Experience)
Performs trend analysis of audit results in order to identify quality system deficiencies.
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Level 4 Behaviors
(Extensive Experience)
Sets audit procedures to monitor data quality following review of varying data and audit reports.
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Level 5 Behaviors
(Mastery)
Leads all facets of audit projects, from implementation to completion to deliver a quality product.
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3 Claims Quality Auditor II - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor II
Proficiency Level - 4
5 Competency for - Claims Quality Auditor II
Proficiency Level - 5

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

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)
Cites examples of SOP practices in our business operations.
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Level 2 Behaviors
(Light Experience)
Compiles and maintains SOPs under our current policies and directions.
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Level 3 Behaviors
(Moderate Experience)
Ensures internal SOPs are in compliance with industry standards and regulations.
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Level 4 Behaviors
(Extensive Experience)
Develops and delivers training programs to ensure our SOPs are fully communicated and adhered to.
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Level 5 Behaviors
(Mastery)
Champions the adoption of SOP to foster efficiency and consistency.
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2 Core Competencies – Attention to Detail
Proficiency Level -3
Skill definition-Executing and completing a task with a high level of accuracy.
Level 1 Behaviors
(General Familiarity)
Cites steps and tips to improve attention to detail in the workplace.
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Level 2 Behaviors
(Light Experience)
Performs assigned responsibilities according to standard procedures and standards.
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Level 3 Behaviors
(Moderate Experience)
Implements a variety of cross-checking approaches and mechanisms.
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Level 4 Behaviors
(Extensive Experience)
Creates and implements quality management processes for our business.
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Level 5 Behaviors
(Mastery)
Defines possible hurdles to projects and creates strategies to deal with them.
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3 Claims Quality Auditor II - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor II
Proficiency Level - 4
5 Competency for - Claims Quality Auditor II
Proficiency Level - 5

Summary of Claims Quality Auditor II skills and competencies

There are 7 hard skills for Claims Quality Auditor II, Insurance Industry, Insurance Legal and Regulatory Environment, Insurance Products, etc.
2 general skills for Claims Quality Auditor II, Quality Assurance, Quality Audit.
8 soft skills for Claims Quality Auditor II, 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 II, he or she needs to be proficient in Standard Operating Procedures (SOP), be skilled in Attention to Detail, and be skilled in Honesty And Integrity.

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