Quality Improvement Research Analyst

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

📋 Description

• Serve as the Quality Subject Matter Expert and provide support to the service delivery team.

• Maintain comprehensive knowledge of internal procedures to address customer inquiries effectively.

• Design, execute, and manage client queries for internal reporting purposes.

• Compile and prepare monthly, quarterly, and ad-hoc reports for designated clients.

• Assess disputed claims within the denial management process concerning system configuration, claims processing, and/or contractual matters.

• Facilitate the health plan's review of claims.

• Assist in resolving operational discrepancies and identifying trends.

• Collaborate with the Service Delivery team and other internal divisions.

• Comprehend departmental requirements and suggest process enhancements.

• Support special projects and assignments that necessitate extensive research.

• Address client inquiries and issues by prioritizing requests and conducting thorough claims investigations.

• Extract claims data and gather information from various departments to identify and resolve operational challenges.

⛳️ Requirements

• A minimum of 3+ years of pertinent work experience in the healthcare sector, including claims processing, claims coding, customer service, and/or account management.

• Bachelor’s degree preferred; alternatively, 5+ years of relevant experience may substitute for a degree.

• Prior experience in a health plan or healthcare service organization is mandatory.

• A solutions-oriented and analytical approach is essential.

• Strong sense of ownership and accountability for results and ongoing improvement is required.

• Excellent communication skills and consistent follow-up to ensure deliverables remain on schedule.

• Proficient written and verbal communication abilities.

• High level of attention to detail, particularly in documentation.

• Familiarity with SQL queries is necessary.

• Advanced computer skills, particularly in Microsoft Office Suite, with a focus on advanced Excel proficiency.

• Experience with data analysis tools is preferred.

• Familiarity with reporting and JIRA is advantageous.

• Experience or certification in medical billing and/or medical coding is a plus.

• Knowledge of laboratory medical coding regulations, compliance issues, reimbursement, and bundling practices is beneficial.

🏝️ Benefits

• Eligibility for remote work.

• Quarterly travel to Avalon’s corporate office located in Tampa, Florida.