Hybrid Wisconsin Claims Quality Assurance Expert

Network Health; Menasha (WI); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Network Health is seeking a Claims Quality Assurance Analyst to support operational excellence, claims accuracy, and regulatory compliance in Wisconsin. This pivotal role conducts audits, reviews, and monitoring of claims to identify trends and opportunities for improvement.

You will collaborate with cross-functional teams, interpret contracts and policies, and contribute to continuous improvement initiatives.

Qualifications

• High school diploma or equivalent.
• 2+ years working in an auditing or claim payment accuracy focused role.
• 2+ years of experience in health care.

Responsibilities

• Perform data entry, claims, enrollment, and operational monitoring activities in accordance with established criteria, methodologies, and timelines.
• Review medical claims, supporting documentation, and medical records, as applicable, to evaluate completeness, accuracy, appropriate payment, and compliance with applicable policies, procedures, contractual requirements, and regulatory standards.
• Conduct claims quality audits and monitoring activities to identify payment discrepancies, processing errors, trends, and opportunities for improved accuracy, efficiency, and consistency.
• Analyze audit and operational results to identify trends and root causes of identified issues and develop meaningful, actionable recommendations for process improvement.
• Compile, document, and communicate audit and monitoring results to leadership and appropriate team members, including identified discrepancies, trends, risks, and recommended corrective actions.
• Maintain accurate and current tracking databases, audit tools, documentation, and files to support quality monitoring and reporting activities.
• Run, review, and compile daily claims inventory reports required to conduct audits and monitoring activities; request and coordinate custom claims reports as needed.
• Support claims audits and monitoring activities related to SLAs, including tracking results and identifying opportunities to improve compliance and performance.
• Assist Internal Audit with MAR functions by performing assigned audit, monitoring, research, documentation, and reporting activities.
• Review and provide feedback on DLP documents to ensure procedures reflect current processing practices, requirements, and processes.
• Research and collaborate with subject matter experts to resolve claims quality issues and determine accurate payment outcomes.
• Maintain strong working relationships with internal and external contacts and demonstrate professionalism and accountability.
• Support department initiatives, projects, and teammates and contribute to department goals and objectives.
• Identify and communicate opportunities to improve claims processes, quality, and operational efficiency.

Skills

Auditing

Claims accuracy

Regulatory compliance

Education

High school diploma

Job description

Network Health is seeking a Claims Quality Assurance Analyst to support operational excellence, claims accuracy, and regulatory compliance in Wisconsin. This pivotal role conducts audits, reviews, and monitoring of claims to identify trends and opportunities for improvement.

You will collaborate with cross-functional teams, interpret contracts and policies, and contribute to continuous improvement initiatives.