displayName
Claims Processing Audit
workflowKind
governance
triggerType
scheduled
typicalCadence
monthly
complexity
cross-team
description
Audits the insurance claims processing pipeline for accuracy and
regulatory compliance -- sampling adjudicated claims for correct
coverage-determination logic, verifying reserve calculations against
actuarial guidelines, reviewing automated-decision model outputs for
bias indicators, validating state-specific regulatory rule application,
and reconciling paid amounts against policy limits and deductible
schedules. Produces audit finding reports, model fairness assessments,
and regulatory compliance scorecards. Excludes claims adjudication
itself.