Raphael & Associates · 13 hours ago
Quality Control Manager - P & C Claims (TPA)
Rutherford, NJ
Full-time
Hybrid
Senior Level
5+ years expRaphael & Associates is a third-party claims administrator and independent claims adjusting company internationally recognized for exceptional service. They are seeking an experienced Quality Control Manager to develop, implement, and maintain quality assurance programs for Property & Casualty claims operations within a Third-Party Administrator. The role focuses on driving accuracy, compliance, and continuous process improvement across claims workflows.
Insurance
Responsibilities
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
Qualification
Required
Bachelor's degree in Business, Insurance, Risk Management, or a related field required
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
Excellent written and verbal communication
Comfortable presenting to executive leadership and engaging at all organizational levels
Strong organization, prioritization, and project management skills
Preferred
Master's degree
CPCU, AIC, ARM, CAMS or Six Sigma/Lean Certification
Prior experience in outsourced TPA quality frameworks vs. captive carrier environments
Benefits
Competitive compensation package
Salary
Bonus
Paid time off
Medical/dental/vision/life insurance
401k (with matching!)
Company
Raphael & Associates
Raphael & Associates is a TPA and claims adjusting company
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Gina Jehn
Head of Human Resources (Part-time)
Company data provided by crunchbase