Claims Quality Assurance Analyst

• Perform thorough weekly quality reviews of Claims and Reimbursement department work processes for accuracy and completeness
• Audit random samples of claim and enrollment specialists’ work
• Evaluate staff understanding of procedures for resolving customer requests
• Evaluate use of standard operating procedures, workflows, and tools
• Document quality reviews by work type and functional area
• Conduct weekly onboarding audits for new employees and provide feedback and coaching support
• Report audit findings to managers and department leaders
• Recommend new or modified processes and procedures to address accuracy errors
• Prepare audit reports for internal business partners
• Serve as subject matter expert for quality audit questions
• Track open audit items and advocate for timely resolution
• Use audit findings and trends to provide training support
• Collaborate with internal business partners to identify procedure gaps and system deficiencies
• Monitor resolution of identified system deficiencies
• Perform other duties as assigned

Requirements

• High School Diploma or GED with at least 5 years of combined experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources OR an Associate Degree in a related field (preferred) with a combination of 2 years of post-degree experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources
• Must live in NC, SC, GA, TN, VA, MD, or FL
• Knowledge of claims adjudication processes, provider contracting and credentialing, and member eligibility
• Well-developed understanding of the health insurance industry
• In-depth understanding of healthcare data analysis
• Proficiency in Microsoft Word, Excel, Outlook, and SharePoint
• Proficiency in or ability to quickly learn the organization’s claims adjudication system and NC Tracks or another multi-payer management information system for NC DHHS
• Strong attention to detail and data accuracy
• Strong computer skills and ability to learn additional databases and review multiple applications/screens simultaneously
• Strong time management skills
• Effective verbal, written, and listening skills
• Ability to make independent decisions and solve challenges in a timely, professional manner
• Ability to work independently and with a team to meet deadlines
• Required training and compliance with HIPAA, 42 CFR Part 2, and applicable confidentiality laws
• Must sign a confidentiality statement
• Ability to perform sedentary work, sit for extended periods, and lift up to 10 pounds
• Close visual acuity and repetitive hand, wrist, and finger motion required

Core Competencies

Demonstrates expertise in quality auditing processes within healthcare claims, with a strong focus on Medicaid and Medicare. Proficient in data analysis, compliance with HIPAA regulations, and effective communication to support training and process improvement.

Highest-signal resume keywords

• Quality Auditing
• Healthcare Claims Processing
• Data Analysis
• Microsoft Office Suite
• HIPAA Compliance

Hard Skills

• Claims Adjudication Processes
• Healthcare Data Analysis
• Attention to Detail
• Time Management
• Independent Decision-Making

Soft Skills

• Effective Communication
• Team Collaboration
• Problem-Solving

Industry Keywords

• Medicaid
• Medicare
• Third Party Payment Sources
• Provider Contracting
• Member Eligibility

Tools & Technologies

• Microsoft Word
• Microsoft Excel
• Microsoft Outlook
• SharePoint
• NC Tracks