Claims Quality & Process Improvement Analyst

Doctors HealthCare Plans, Inc.; Coral Gables (FL); On-site; USD 85,000 - 115,000; Full time

Job summary

Doctors HealthCare Plans, Inc. is seeking a Claims Quality Business Analyst to analyze claims operations, verify payment accuracy, and ensure regulatory compliance across CMS/AHCA requirements.

You will liaison between Claims, Compliance, Quality, IT, and Provider Relations, develop quality dashboards, perform UAT, and drive process improvements to reduce rework and improve member/provider satisfaction.

Qualifications

• Bachelor's degree in healthcare/related field.
• 3–5 years in health plan claims operations or healthcare analytics.
• Experience with Medicare Advantage/Medicaid/managed care claims processing.
• Strong analytical and reporting skills.

Responsibilities

• Monitor claims processing accuracy, timeliness, and CMS/AHCA compliance.
• Conduct root cause analyses on claim errors and denials.
• Develop and maintain claims quality monitoring reports and dashboards.
• Gather business requirements for system enhancements and improvements.
• Collaborate with IT, Quality, Compliance, and Provider Relations on changes.
• Lead regulatory and compliance support related to RA/EOB content and codes.

Skills

Analytical skills

Reporting skills

Data analysis

Regulatory compliance

Cross-functional collaboration

Education

Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field

Tools

Facets

QNXT

HealthRules

Job description

Doctors HealthCare Plans, Inc. is seeking a Claims Quality Business Analyst to analyze claims operations, verify payment accuracy, and ensure regulatory compliance across CMS/AHCA requirements.

You will liaison between Claims, Compliance, Quality, IT, and Provider Relations, develop quality dashboards, perform UAT, and drive process improvements to reduce rework and improve member/provider satisfaction.