Claims Quality Assurance Analyst

This is a fully remote position, open to applicants in Florida, +5 more states.

📋 Description

• Conduct comprehensive weekly quality assessments of the Claims and Reimbursement department's workflows to ensure accuracy and completeness.

• Audit random selections of the work completed by claim and enrollment specialists.

• Assess staff comprehension of procedures for addressing customer inquiries.

• Review the application of standard operating procedures, workflows, and tools.

• Document quality assessments by work type and functional area.

• Execute weekly onboarding audits for new hires, providing constructive feedback and coaching support.

• Communicate audit results to managers and departmental leaders.

• Suggest new or revised processes and procedures to correct accuracy issues.

• Compile audit reports for internal stakeholders.

• Act as the subject matter expert for inquiries related to quality audits.

• Monitor unresolved audit items and advocate for their prompt resolution.

• Utilize audit insights and trends to offer training assistance.

• Collaborate with internal partners to pinpoint procedural gaps and system shortcomings.

• Oversee the resolution of identified system flaws.

• Perform additional duties as assigned.

⛳️ Requirements

• High School Diploma or GED with a minimum of 5 years of combined experience in healthcare claim processing, particularly with Medicaid, Medicare, and other third-party payment sources, or an Associate Degree in a relevant field (preferred) along with 2 years of post-degree experience in healthcare claim processing.

• Residency required in NC, SC, GA, TN, VA, MD, or FL.

• Familiarity with claims adjudication processes, provider contracting and credentialing, and member eligibility.

• Solid understanding of the health insurance sector.

• Extensive knowledge of healthcare data analysis.

• Proficient in Microsoft Word, Excel, Outlook, and SharePoint.

• Proficient in or able to swiftly learn the organization’s claims adjudication system and NC Tracks or another multi-payer management information system for NC DHHS.

• Exceptional attention to detail and data accuracy.

• Strong computer skills with the capability to learn additional databases and navigate multiple applications/screens simultaneously.

• Excellent time management abilities.

• Strong verbal, written, and listening communication skills.

• Capacity to make independent decisions and resolve issues promptly and professionally.

• Ability to work autonomously as well as collaboratively to meet deadlines.

• Required training and compliance with HIPAA, 42 CFR Part 2, and related confidentiality regulations.

• Must sign a confidentiality agreement.

• Capability to perform sedentary work, sit for prolonged periods, and lift up to 10 pounds.

• Close visual acuity and repetitive hand, wrist, and finger motions are necessary.

🏝️ Benefits

• Exempt position.

• Not eligible for overtime compensation.

• Remote, home-based work arrangement.

• Monday–Friday schedule.