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%
$56,630
TOTAL 50%
$58,201
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)
Defines the key terminologies and components of an insurance policy.
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Level 2 Behaviors
(Light Experience)
Enters new information about insurance premiums and payments to update insurance policy records.
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Level 3 Behaviors
(Moderate Experience)
Examines insurance applications and letters from clients to determine necessary policy changes.
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Level 4 Behaviors
(Extensive Experience)
Evaluates existing claims handling process to identify fraud and opportunities for optimization of outcomes.
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Level 5 Behaviors
(Mastery)
Champions the adoption of AI and automation technologies to streamline insurance operations.
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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)
Cites examples of the legal principles of insurance applicable to multiple types of insurance products.
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Level 2 Behaviors
(Light Experience)
Assists in assessing regulatory risks to ensure insurance operations meet compliance and regulatory obligations.
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Level 3 Behaviors
(Moderate Experience)
Adopts legal and regulatory initiatives to assess possible risks and maintain insurance solvency.
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Level 4 Behaviors
(Extensive Experience)
Directs the regulation of insurance products to ensure insurance policy provisions comply with state laws.
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Level 5 Behaviors
(Mastery)
Builds policy and regulatory tools to monitor and assess compliance levels with insurance laws and regulations.
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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)
Cites quality assurance development and implementation processes, structure, and best practices.
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Level 2 Behaviors
(Light Experience)
Assists in the implementation of a quality assurance improvement plan to enhance quality assurance procedures.
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Level 3 Behaviors
(Moderate Experience)
Administers quality assurance efforts to guarantee compliance with program policies and guidelines.
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Level 4 Behaviors
(Extensive Experience)
Evaluates critical data to identify areas for improvement in quality assurance systems.
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Level 5 Behaviors
(Mastery)
Advocates safe operations and lost time reduction through compliance with quality assurance protocols.
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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)
Describes methodologies and techniques for effective quality audit reports.
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Level 2 Behaviors
(Light Experience)
Assists in internal audits to determine compliance with quality management system standards.
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Level 3 Behaviors
(Moderate Experience)
Administers both product and process audits to quality standards throughout all stages of the manufacturing process.
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Level 4 Behaviors
(Extensive Experience)
Delivers strategic recommendations to improve the quality of overall operations based on audit observations.
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Level 5 Behaviors
(Mastery)
Builds a self-audit program for our business to drive quality system and process improvements.
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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)
Assists in the preparation of internal standard operating procedures (SOP).
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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)
Keeps full attention when listening to understand the message.
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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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