Claims Quality Assurance Analyst

The Claims Quality Assurance Analyst is responsible for monitoring and documenting production quality in support of departmental goals and initiatives, with a primary focus on claims auditing and claims-related interactions within the Revenue Cycle Management (RCM) function. The Claims Quality Assurance Analyst reviews claim audit results and claim transactions, as well as evaluates both verbal and written contacts, to ensure accuracy, completeness, proper documentation, and compliance with policies, procedures, and applicable regulations.

The Analyst supports the design and maintenance of quality monitoring formats and standards, documents quality findings, and effectively presents results, feedback, and trend data to leadership to drive continuous improvement. The ideal candidate has prior healthcare claims auditing experience, working knowledge of claims billing practices and state billing requirements. DME claims experience is preferred.

While this role is primarily focused on claims audit activities, the Analyst may also support quality monitoring and audit needs across other operational areas based on business priorities.

• Primarily monitor Claims quality and audit functions, with support for other operational departments as business needs require; DME claims experience preferred
• Participate in and support the design of quality monitoring forms and quality standards
• Record evaluations utilizing departmental quality monitoring forms
• Conduct claims audit reviews to confirm claim accuracy, required documentation, workflow adherence, and compliance with internal policies and applicable requirements
• Evaluate claim handling for appropriate billing practices, including awareness of state-specific billing requirements as applicable to the claim type and line of business
• Support Revenue Cycle Management (RCM) quality outcomes by identifying audit findings that drive denials, rework, or reimbursement issues and partnering with operations to reduce defects
• Identify and trend audit findings (e.g., documentation deficiencies, timeliness, process gaps, billing errors) and communicate actionable insights to leadership and operations partners
• Collect, evaluate, report on and track operations data against performance metrics
• Prepare and analyze quality reports for Management review
• Prepare and facilitate quality calibration sessions with designated department leads
  · Facilitate meetings and prepare presentations related to insight analysis
• Collaborate with the leadership team to create content-based training that will equip operations personnel with the necessary skills for success
• Monitor trends and provide input or feedback on the information reported on
• Identify, analyze and share ways to optimize the quality monitoring process
• Complete all evaluations, reports and employee coaching sessions on a timely basis
• Ability to learn new systems, tools, and methodologies as needed and continue progressing in a dynamic environment
• Support ad hoc quality monitoring, reporting and analysis activities based on operational needs
• Work and communicate cross-departmentally

• Minimum of 1 year of claims auditing experience supporting commercial, Medicaid, and Medicare lines of business, including working knowledge of billing rules and state/payer-specific requirements; DME preferred. Other QA/production experience a plus (or equivalent education and experience).
• Working knowledge of Revenue Cycle Management (RCM) workflows and downstream impacts (e.g., clean claim submission, edits, denials, appeals, payment posting/reconciliation) across commercial, Medicaid, and Medicare.
  · Desire and capability to emerge as a leader within the Operations team
• Consistent track record of 95% + in Quality and Production scores in current/previous roles
• Proficient understanding of QA methodologies and quality monitoring practices
• Demonstrated ability to rapidly gain product, process and tools knowledge and effectively communicate it to employees
• Ability to analyze data to identify root causes of quality issues and propose actionable solutions
• Excellent communication skills including listening,…