Claims Quality Assurance Analyst

Jobtailor; Deutschland; Remote; EUR 40.000 - 56.000; Vollzeit

Zusammenfassung

Jobtailor is seeking a Quality Assurance Auditor for our Claims & Reimbursement team to ensure accuracy and compliance across processing workflows. You will conduct weekly quality reviews, audit samples, document findings, and provide coaching feedback to onboarding staff.

You will report audit results to managers, identify gaps, and recommend process improvements. Strong data analysis, HIPAA knowledge, and proficiency with NC Tracks/SharePoint are required.

Qualifikationen

• High School Diploma or GED with at least 5 years of combined experience in health care claim processing for Medicaid/Medicare/3rd party payers.
• Alternatively, an Associate Degree with 2 years post-degree experience in health care claim processing.
• Must live in NC, SC, GA, TN, VA, MD, or FL.
• Knowledge of claims adjudication processes, provider contracting and credentialing, and member eligibility.
• Strong data analysis and HIPAA compliance knowledge.

Aufgaben

• 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.
• Document quality reviews by work type and functional area.
• Prepare audit reports for internal business partners.
• Serve as subject matter expert for quality audit questions.
• Report audit findings to managers and department leaders.
• Recommend new or modified processes and procedures to address accuracy errors.
• Collaborate with internal business partners to identify procedure gaps and system deficiencies.
• Monitor resolution of identified system deficiencies.
• Perform other duties as assigned.

Kenntnisse

Quality Auditing

Healthcare Claims Processing

Data Analysis

Microsoft Office

HIPAA Compliance

Ausbildung

High School Diploma or GED

Associate Degree in related field

Tools

NC Tracks

SharePoint

Microsoft Word

Microsoft Excel

Microsoft Outlook

Jobbeschreibung

• 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