Quality Control Manager - P & C Claims (TPA)
This position will be located at our Rutherford, New Jersey home office. Consideration will be made for Remote based candidates. Key Responsibilities Quality Assurance and Audit
- Design and implement quality measurement tools , scorecards, checklists, and sampling methodologies.
- Define, maintain, and evolve quality assurance standards for P&C claims.
- Conduct regular quality audits , sampling claims across adjusters, teams, and lines of business.
- Ensure consistent application of standards, policies, and procedures across claims operations.
- Document and report findings. Provide actionable recommendations and monitor corrective action plan.
- Lead initiatives to improve claims accuracy, cycle times, compliance, and customer outcomes .
- Partner with operations leadership to identify training needs based on quality trends.
- Facilitate or deliver quality-focused training sessions for claims adjusters and supervisors.
- Drive projects to implement best practices, process enhancements, and automated quality controls .
- Serve as a subject matter expert and trusted advisor to Claims Operations Leadership.
- Work cross-functionally with training, compliance, operations, IT, and risk management teams.
- Coach and mentor quality analysts and support staff.
- Provide regular briefings to senior leadership on quality results, risks, and improvement plans.
- Establish and track quality KPIs , such as:
- Claims accuracy rate.
- Documentation completeness/consistency.
- Severity, subrogation, and reserve accuracy.
- Cycle time variances.
- Error rates by adjuster/team.
- Lead root cause analysis and track corrective action effectiveness .
- Ensure QA programs comply with state insurance regulations , industry standards, and contractual obligations.
- Maintain familiarity with NAIC guidelines , state-specific claims handling regulations (e.g., unfair claim settlement practices), and audit requirements.
- Support internal and external regulatory exams and audits as needed.
- Bachelor’s degree in Business, Insurance, Risk Management, or a related field required; Master’s degree preferred.
- Preferred Certifications:
- CPCU, AIC, ARM, CAMS or Six Sigma/Lean Certification.
- 5+ years of experience in P&C claims operations within a TPA, insurance carrier, or equivalent environment.
- 3+ years of experience in quality, quality control, or audit functions , specifically supporting P&C claims.
- Strong understanding of P&C policy coverages, claims lifecycle, adjudication standards , and claims documentation best practices.
- Experience with industry quality standards and tools.
- Prior experience in outsourced TPA quality frameworks vs. captive carrier environments is a plus.
- Excellent written and verbal communication .
- Comfortable presenting to executive leadership and engaging at all organizational levels.
- Strong organization, prioritization, and project management skills.
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