Quality Control Manager - P & C Claims (TPA)

Company : Raphael And Associates

Job Description - Quality Control Manager - P & C Claims (TPA)

We are seeking an experienced Quality Control Manager to join our team. This role will be responsible for developing, implementing, and maintaining quality assurance programs for Property & Casualty claims operations within a Third-Party Administrator (TPA). This role drives accuracy, consistency, compliance with regulatory and internal standards, and continuous process improvement across claims workflows.
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.

Continuous Improvement

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.

Leadership and Interaction

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.

Metrics & KPI Accountability

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.

Regulatory & Compliance Requirements

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.

Qualifications

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.

About Raphael and Associates

Raphael & Associates is a third-party claims administrator and independent claims adjusting company internationally recognized for exceptional service. We understand the importance of adapting to the demands of a dynamic market and we tailor our services to our client’s specific needs. As a claim’s organization, what we do is complex. Our mission is simple: to provide outstanding service, retain extraordinary professionals, and utilize the best technology in the industry!

As a leading organization in the industry, we offer dynamic and challenging opportunities to individuals who want to make a difference. We value camaraderie, vision, a passion for excellence, creativity, and self-reliant professionals.

Benefits and Perks

We are an organization that recognizes and appreciates hard work! We offer a competitive compensation package commensurate with experience, including salary, bonus, paid time off, medical/dental/vision/life insurance and 401k (with matching!). Most importantly, you will have the opportunity to work directly alongside an extraordinary and dedicated team to grow a critical function within a dynamic, growing company.

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Quality Control Manager - P & C Claims (TPA)

Job Description - Quality Control Manager - P & C Claims (TPA)

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