QA Engineer

• Conduct comprehensive quality audits of inbound and outbound call center interactions, ensuring accuracy, regulatory compliance, and adherence to TPA standard operating procedures.
• Review and audit completed service and administrative forms (e.g., policy changes, beneficiary updates) for completeness, accuracy, and proper processing workflow.
• Deliver timely, objective, and constructive feedback and coaching to call center agents and team leads to improve service quality and transaction accuracy.
• Track, analyze, and report on key TPA and QA metrics and trends, identifying root causes of errors and compliance gaps.
• Act as the initial point of contact for internal fraud referrals (SIU). Review and analyze cases flagged for potential fraudulent activity, including claims, policy changes, and applications.
• Collect, organize, and summarize documentation and system history related to suspicious cases.
• Conduct preliminary analysis to determine the validity of the fraud concern. Prepare and present well-documented case files for formal referral to the insurance carrier’s Special Investigations Unit (SIU).
• Maintain detailed and confidential records of all investigation activities and findings in accordance with internal protocol and regulatory requirements.
• Execute periodic and event-based monitoring of defined key operational and financial controls within the TPA processing environment to confirm effectiveness.
• Assist in the reporting of control gaps, deficiencies, and emerging risks to the Risk and Compliance leadership.
• Collaborate with Operations and Training teams to develop and implement targeted process changes, control enhancements, and improved documentation to mitigate identified risks.
• Assist in the development and delivery of training modules related to compliance, fraud awareness, and new quality standards for operations, quality assurance and TPA contact center staff.

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