Description
Audit open and closed claim files, payments, reserves, and litigation expenses to ensure accuracy, regulatory compliance, and adherence to company policies. Identify errors, overpayments, control gaps, and fraud indicators; report findings, recommend corrective actions, and partner with claims, legal, compliance, and finance to improve quality and reduce loss leakage.
- • Request clarifications from adjusters, SIU, agents, or claimants to resolve discrepancies.
- • Verify that statements and evidence support settlement decisions and denials.
- • Test timeliness, fair claims practices, and file handling quality against standards.
- • Review reserve adequacy and escalation practices; recommend adjustments when warranted.
- • Perform deep-dive audits of complex, high-exposure, or litigated claims.
- • Test payment accuracy, authority levels, and financial controls, including duplicates.
- • Conduct targeted audits of suspect or anomalous claims and refer to SIU when indicated.
- • Validate calculations and data used in settlements for accuracy and policy compliance.
- • Document audit workpapers and results in audit and claim systems.
- • Escalate significant noncompliance or potential fraud to management, SIU, or compliance.
- • Compile audit evidence for litigation, arbitration, DOI inquiries, or external audits.
- • Consult with legal counsel on litigated file handling, costs, and guideline adherence.
- • Obtain supplemental documentation from providers, employers, or experts to validate bills or wage loss.
- • Maintain an audit inventory and track corrective actions to closure.
- • Present audit results, trends, and root causes at claim and quality meetings.
- • Coach claim staff and provide feedback to improve file quality and compliance.
- • Audit vendor, panel counsel, and litigation invoices for rate, activity, and guideline adherence.
- • Review coverage and ownership or insurable interest determinations as applicable.
- • Identify and report overpayments, underpayments, subrogation misses, and other irregularities; initiate recovery.
- • Validate reinsurance reporting and recoveries with reinsurance and finance teams.
- • Produce audit reports, dashboards, and data requests for management and regulators.
- • Use data analytics and sampling to select files and identify outliers or trends.
- • Audit claim forms, coverage determinations, and policy data for accuracy and compliance.
- • Analyze file documentation and summarize audit findings with recommendations.
- • Review police reports, medical records, and repair estimates to validate liability and damages assessments.
- • Evaluate property and auto damage estimates for accuracy versus guidelines and tools.
- • Perform pre-mediation or pre-trial file audits to assess strategy and cost controls.
- • Validate wage, employment, and earnings documentation procedures on related claims.
- • Recommend process improvements, training, or policy changes to reduce loss leakage.
- • Verify remediation effectiveness through follow-up testing and continuous monitoring.
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Financial Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
