Claims Quality Assurance Specialist

Vela Insurance Services provides specialized Excess and Surplus Lines Casualty and Professional Liability insurance solutions in Construction, Specialty Casualty, and Professional Liability segments. We offer national service and local knowledge to our exclusive wholesale broker network and the businesses they serve.

The Quality Assurance – Claims role is responsible for supporting the VP of Claims through file audits, reserving oversight, and Medicare reporting for the Claim Department. This position will conduct reserve reviews, lead and participate in monthly claim file audits, and perform Medicare reporting reviews. The role ensures that managers and adjusters comply with all quality standards, compliance requirements, and best practices set forth by the company.

It also maintains and acts on audit results and required actions in conjunction with claim leadership and compliance. The ideal candidate will be highly organized and responsive, consistently meeting deadlines.

• Conduct File Reviews:
  Perform structured reviews of claim files to ensure compliance with internal and external requirements and best practices, maintaining consistency and objectivity across the Claim Department.
• Assess File Quality, Coverage & Reserves:
  Identify, document, and evaluate file quality and reserve sufficiency, providing constructive feedback to drive continuous improvement.
• Support SOX Claim Compliance:
  Assist Claim Leadership in executing SOX compliance initiatives, including reviewing best practices, updating SOX Claim Narratives, and testing claim controls (QA, Large Loss, SOPs, Best Practices, Claim Authorities). Contribute to the development of processes and procedures to improve audit results.
• Facilitate Calibration Discussions:
  Partner with claim managers to ensure consistency in claim file reviews, reserving standards, and adherence to best practices.
• Ensure Regulatory Compliance:
  Maintain compliance with applicable Medicare reporting requirements, updating claim files as necessary to ensure accuracy and adherence to all regulations.
• Additional duties as assigned.
• Regular and predictable attendance.

• Four (4) year college degree, JD preferred, or commensurate experience and training.
• Proven proficiency in managing claims across all product lines and coverages.
• Strong ability to audit and evaluate claim files and establish accurate reserves.
• Thorough knowledge of organizational policies, claim best practices, regulatory requirements, and claims handling processes.
• Solid background in coverage and liability assessment, property damage, bodily injury, New York Labor Law, construction defect claims, and management of both non‑litigated and litigated matters.
• Collaborative, affable skills with a common goal of achieving state‑of‑the‑art claim service.
• Minimum of seven years of experience handling complex litigated claims in all lines of business.
• Minimum of three years conducting claim file audits.
• Experience with a variety of claim systems including Guide Wire’s Claim Center and audit tools such as C2
  
  Perform and others.
• Technical acumen and working knowledge of Excel.
• Strong coverage knowledge across multiple lines of business including Professional Liability, General Liability, Products, Construction Liability, and Construction Defect.
• Strong knowledge of multiple jurisdictions.
• Strong knowledge of trial process and litigation management.
• Five years progressive leadership experience in a claim organization.
• Adjuster licenses as required.

The Company Is An Equal Employment Opportunity Employer.

Sponsorship not Offered for this Role.