Claims Operations Quality Assurance Specialist

Job Description:

Pacific Life is seeking talented Operations Quality Assurance Specialists to join our Consumer Markets Division in Omaha, NE or Charlotte, NC.

In this role, you will play a critical part in ensuring the accuracy, compliance, and quality of life insurance claims processing activities. You will conduct detailed transaction audits, identify trends and root causes, and provide actionable insights that improve operational performance, reduce risk, and strengthen service quality across the organization.

This is an excellent opportunity for individuals looking to grow their career in operations quality, risk, and process improvement within a leading financial services organization.

• Perform detailed quality audits of claims transactions across Pay QA, Set-Up QA, and Follow-Up QA, including claim payment accuracy, interest review and calculation, post-death interest, initial claim setup, documentation, beneficiary/payee information, follow-up requirements, and completion of required claim actions
• Evaluate claims processing for adherence to established procedures, authority guidelines, controls, regulatory requirements, service standards, and customer-focused claim handling expectations
• Document QA findings for pay, set-up, and follow-up reviews, including defect type, root cause, severity, risk impact, coaching opportunity, and recommended corrective action
• Partner with claims leaders, processors, trainers, and business partners to clarify expectations, reinforce procedures, and support corrective action planning when quality gaps are identified
• Analyze QA results to identify trends in payment errors, setup accuracy, missing or incomplete documentation, follow-up timeliness, procedural gaps, and recurring claim handling themes
• Contribute to claims QA reporting and insight development that helps leadership understand risk areas, training needs, workload impacts, and opportunities to improve claim quality and consistency
• Support continuous improvement initiatives aimed at increasing quality, efficiency, and consistency
• Participate in calibration sessions for Pay QA, Set-Up QA, and Follow-Up QA to ensure review accuracy, consistent scoring, and alignment across QA reviewers and claims operations

• Consistently apply sound judgment and accountability when evaluating pay accuracy, interest review and calculation, post-death interest, claim setup completeness, follow-up activity, documentation quality, and adherence to claims procedures
• Identify meaningful trends and root causes across Pay QA, Set-Up QA, and Follow-Up QA that help reduce repeat errors, strengthen controls, and improve the customer claim experience
• Deliver timely, accurate, objective, and actionable QA findings through clear documentation, consistent scoring, and constructive communication with claims processors and leaders
• Build strong partnerships with claims operations stakeholders to support coaching, quality improvement, procedural alignment, and consistent claim handling practices
• Contribute to a culture of continuous improvement by using QA insights to support training, reduce risk, improve claim accuracy, and strengthen operational excellence

• 1-4 years of experience in claims processing, claims quality assurance, auditing, compliance, insurance operations, financial operations, or operational risk/control environments
• Strong analytical and critical thinking skills with the ability to identify claim processing patterns, root causes, procedural gaps, and risk trends across QA review results
• Exceptional attention to detail and documentation accuracy
• Ability to interpret and apply claims procedures consistently while exercising sound judgment in pay, set-up, and follow-up review scenarios
• Strong communication and partnership skills with the ability to provide constructive, fact-based feedback to claims processors, leaders, and training partners
• Ability to manage multiple priorities in a fast-paced environment
• Demonstrated adaptability and learning agility

• Experience in life insurance claims, financial services, banking, healthcare claims, or other regulated operational environments
• Prior experience with claims quality assurance, claim payment review, claim setup review, follow-up review, audit, compliance, or controls work
• Knowledge of claims operations, life insurance claim handling, beneficiary/payee review, documentation requirements, payment controls, interest calculation, and post-death interest review
• Experience supporting process improvement or operational excellence initiatives

This role may be filled at either the Specialist or Sr Specialist level based on qualifications and experience.

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