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)
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)
Identifies cost-effective solutions to address regulatory compliance challenges in insurance services.
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Level 4 Behaviors
(Extensive Experience)
Facilitates discussions with agents and underwriters on evolving exposures and risk management practices.
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Level 5 Behaviors
(Mastery)
Designs and executes innovative strategies and techniques to optimize the claims-handling process.
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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)
Describes the basic structure of insurance legal and regulatory environment.
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Level 2 Behaviors
(Light Experience)
Complies with insurance legal and regulatory principles to safeguard the rights and interests of the insured.
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Level 3 Behaviors
(Moderate Experience)
Analyzes existing legal and regulatory standards to address errors affecting insurance policies.
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Level 4 Behaviors
(Extensive Experience)
Improves legal procedures for licensing intermediaries or producers to prevent penalties.
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Level 5 Behaviors
(Mastery)
Designs compliance strategies and programs to prevent violations of statutes, regulations, and policies.
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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)
Describes the significance of data warehousing best practices in maintaining quality assurance.
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Level 2 Behaviors
(Light Experience)
Compiles statistical data and narrative reports to summarize quality assurance findings.
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Level 3 Behaviors
(Moderate Experience)
Executes quality chart audits to address quality assurance-related issues and identify areas for improvement.
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Level 4 Behaviors
(Extensive Experience)
Guides the quality improvement teams to minimize quality issues while recommending process improvements.
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Level 5 Behaviors
(Mastery)
Develops quality assurance activities to promote adherence to standards and best practices.
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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)
Explains the relationship of the International Organization for Standardization (ISO) 9001 standard in the quality audit.
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Level 2 Behaviors
(Light Experience)
Compiles all quality-related documentation to easily access regulatory audits.
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Level 3 Behaviors
(Moderate Experience)
Implements appropriate audit procedures to ensure high-quality standards and compliance.
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Level 4 Behaviors
(Extensive Experience)
Determines the need for computer-assisted audit techniques and develops quality audit programs for process improvement.
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Level 5 Behaviors
(Mastery)
Champions quality self-assessment programs to build and sustain an audit-ready-now environment.
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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)
Describes the purposes and benefits of Standard Operating Procedures (SOP).
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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)
Explains why attention to detail plays an important role in own function or unit.
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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)
Demonstrates expertise in quality assurance tools, techniques, and standards.
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Level 5 Behaviors
(Mastery)
Designs techniques for measuring the cost and impact of errors.
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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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