Skills & Competencies for Claims Quality Auditor III

Claims Quality Auditor III job profile

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JOB SUMMARY for Claims Quality Auditor III

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

JOB RESPONSIBILITIES for Claims Quality Auditor III

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

Claims Quality Auditor III SALARY RANGE

BASE 50%
$65,923
TOTAL 50%
$67,999
Job Level
P04
Job Code
HC07000628
Education/Degree
Associate's Degree
Reports To
Supervisor or Manager

Claims Quality Auditor III 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 III 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 III

1 Industry Competency – Insurance Industry
Proficiency Level -3
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)
Describes the current systems and scope of services provided by insurance organizations.
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Level 2 Behaviors
(Light Experience)
Follows industry best practices when preparing reports that detail risk assessment findings in insurance claims.
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Level 3 Behaviors
(Moderate Experience)
Makes necessary adjustments to insurance policies to meet customer needs.
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Level 4 Behaviors
(Extensive Experience)
Handles complex insurance losses through negotiation of favorable claims settlements with insurance companies.
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Level 5 Behaviors
(Mastery)
Develops and establishes risk reduction best practices to prevent fraudulent claims transactions.
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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 III - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor III
Proficiency Level - 4
5 Competency for - Claims Quality Auditor III
Proficiency Level - 5

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

1 Job Family Competencies – Quality Assurance
Proficiency Level -3
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 -4
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)
Lists the differences between various types of quality audits including product, process, and systems audits.
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Level 2 Behaviors
(Light Experience)
Reports quality audit activities, results, and key metrics to drive continuous improvement activities.
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Level 3 Behaviors
(Moderate Experience)
Partners with management in initiating annual product quality reviews concerning audit-related information.
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Level 4 Behaviors
(Extensive Experience)
Oversees the implementation of corrective actions to address underlying issues identified during quality audits.
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Level 5 Behaviors
(Mastery)
Establishes audit compliance governance processes to ensure robust processes met stakeholder expectations.
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3 Claims Quality Auditor III - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor III
Proficiency Level - 4
5 Competency for - Claims Quality Auditor III
Proficiency Level - 5

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

1 Core Competencies – Standard Operating Procedures (SOP)
Proficiency Level -3
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)
Identifies our internal and external sources for the SOPs we need.
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Level 2 Behaviors
(Light Experience)
Participates in the implementation of new SOPs and enhancement of existing ones.
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Level 3 Behaviors
(Moderate Experience)
Maintains the accuracy of SOPs to provide consistent guidance in our workplace.
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Level 4 Behaviors
(Extensive Experience)
Leverages the use of SOPs to solve business and operation problems.
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Level 5 Behaviors
(Mastery)
Keeps abreast of industry regulation and its effect on our internal SOPs.
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2 Core Competencies – Attention to Detail
Proficiency Level -4
Skill definition-Executing and completing a task with a high level of accuracy.
Level 1 Behaviors
(General Familiarity)
Lists best practices and tools to maintain high accuracy and thoroughness in the workplace.
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Level 2 Behaviors
(Light Experience)
Uses checklists to ensure that information goes out error-free.
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Level 3 Behaviors
(Moderate Experience)
Sets up processes to ensure delivery of high-quality work.
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Level 4 Behaviors
(Extensive Experience)
Employs techniques for motivating personnel to meet or exceed accuracy goals.
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Level 5 Behaviors
(Mastery)
Leads the creation of tools for enhancing and assuring accuracy.
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3 Claims Quality Auditor III - Skill and Competency
Proficiency Level - 3
4 Skill and Competency - Claims Quality Auditor III
Proficiency Level - 4
5 Competency for - Claims Quality Auditor III
Proficiency Level - 5

Summary of Claims Quality Auditor III skills and competencies

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

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