Quality Assurance Specialist

This is a fully remote position, open to applicants in New Hampshire.

📋 Description

• Conduct daily audits of medical claims both before and after payment.

• Confirm the application of benefits, which includes checking deductibles, copays, coinsurance, eligibility, and plan specifics.

• Assess the accuracy of provider network tiering and reimbursement.

• Ensure claims are processed in alignment with provider contracts, fee schedules, and client plan designs.

• Detect, record, and relay any errors and trends in claim processing.

• Execute audits related to production, system configuration, and operational quality.

• Carry out LDLA (Licensee Desk Level Audit) and MTM (Member Touchpoint Measurement) evaluations.

• Assist in external client, regulatory, and internal audit initiatives.

• Engage in testing activities for new clients, renewals, and plan modifications.

• Create audit reports and suggest corrective measures along with process enhancements.

• Work collaboratively with Claims, Provider Maintenance, Customer Service, Configuration, and Implementation teams to address quality concerns.

⛳️ Requirements

• An associate degree or a relevant combination of education and experience.

• At least 3 years of experience in health insurance claims processing, auditing, or quality assurance.

• Comprehensive knowledge of medical claims adjudication and benefit management.

• Experience in reviewing provider contracts, pricing strategies, and network frameworks.

• Exceptional analytical, organizational, and problem-solving abilities.

• Proficient in Microsoft Office applications, including Excel, Word, Outlook, and Teams.

• Strong written and verbal communication capabilities.

• Ability to work autonomously while juggling multiple priorities.

• Preferred: Experience with self-funded health plans and healthcare TPA settings.

• Preferred: Familiarity with Blue Cross Blue Shield processes and standards.

• Preferred: Experience with Javelina or comparable claims administration systems.

• Preferred: Knowledge of provider network tiering and implementation testing.

• Must meet employment eligibility verification through E-Verify.

🏝️ Benefits

• Excellent medical, dental, and vision insurance plans.

• Biannual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible.

• Basic Life and AD&D insurance provided by the company.

• Short-Term and Long-Term Disability paid for by the company.

• Flexible Spending Accounts available.

• 401(k) Retirement Plan with an employer match of up to 6%.

• More than 10 paid holidays each year.

• Fully paid half-day Summer Fridays.

• Generous paid vacation and sick leave.

• One paid volunteer day each year.

• Annual tuition reimbursement offered.

• Annual health and wellness reimbursement available.

• Numerous fun company events throughout the year.