Mid-Level Claims Quality Analyst (Remote)

Jobright.ai; United States; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Life Insurance

Health Insurance

401K retirement plan

Short- and long-term disability

Tuition reimbursement

Business casual dress

Job summary

Wellfleet, a Berkshire Hathaway company, seeks a Claims Quality Analyst to review claims for accuracy, validity, and timeliness, ensuring compliance with internal controls. The role supports training, analyses error trends, and coordinates with High Dollar review teams to improve claim processing and financial performance.

The candidate should have a Bachelor's degree in healthcare insurance or equivalent experience, with proficiency in medical terminology, ICD-10, CPT/HCPCS codes, and claims

Qualifications

• Claims audit experience
• Proficiency with medical terminology, ICD-10, CPT/HCPCS, plan documents and regulations
• Experience with LuminX or other claims systems
• Claim audit or extensive claim processing experience
• Excellent communication skills, both verbal and written
• Detail-oriented with strong organizational skills
• Ability to balance multiple responsibilities independently or in a team

Responsibilities

• Interact with other claims quality analysts on pre-payment and post-payment claim reviews to ensure validity and accuracy of claims as well as the timeliness of reviewed claims
• Audit system configuration of benefit plans against plan documents and report any discrepancies
• Perform pre-payment claim review for Wellfleet TPA’s claims in excess of authority limit
• Serve as SME on LuminX claims processing; maintain LuminX audit parameters to meet internal and industry standards for claim review levels
• Report claims review results to the Claims Department; including detailed analysis of errors within required timeframe and support training/education efforts to reduce Claims Specialist processing errors
• Perform testing tasks and document findings on all completed projects, in coordination with the Claims Configuration & Quality Assurance Manager
• Coordinate with and provide detailed claim information to High Dollar review team
• Identify trends of claim errors and work with claims and plan configuration to establish process improvement methods
• Perform other duties as assigned

Skills

Claims audit

LuminX processing

Medical terminology

Data mining

Microsoft Office Suite

Analytical skills

Communication skills

Organizational skills

Problem-solving

Education

Bachelor's degree in healthcare insurance or related field

Tools

LuminX

SQL

Microsoft Office Suite

Job description

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance. The Claims Quality Analyst is responsible for claims quality review practices and processes aimed at improving claim handling, financial performance, and customer satisfaction while ensuring compliance with internal control standards.

Human Resources Healthcare Property & Casualty Insurance Health Insurance Employee Benefits Health Care Insurance InsurTech Life Insurance

Responsibilities

Interact with other claims quality analysts on pre-payment and post-payment claim reviews to ensure validity and accuracy of claims as well as the timeliness of reviewed claims

Audit system configuration of benefit plans against plan documents and report any discrepancies

Perform pre-payment claim review for Wellfleet TPA’s claims in excess of authority limit

Serve as SME on LuminX claims processing; maintain LuminX audit parameters to meet internal and industry standards for claim review levels

Report claims review results to the Claims Department; including detailed analysis of errors within required timeframe and support training/education efforts to reduce Claims Specialist processing errors

Perform testing tasks and document findings on all completed projects, in coordination with the Claims Configuration & Quality Assurance Manager

Coordinate with and provide detailed claim information to High Dollar review team

Identify trends of claim errors and work with claims and plan configuration to establish process improvement methods

Perform other duties as assigned

Qualification

Claims audit experience LuminX claims processing Medical terminology Data mining tools Microsoft Office Suite Analytical skills Communication skills Organizational skills Problem-solving skills

Required

Bachelor's degree in healthcare insurance or related field or 5+ years of equivalent experience in the field

Demonstrates proficiency and understanding of medical terminology, icd 10 codes, cpt/hcpc procedure codes, plan documents, claim terminology and state and federal regulations

Experience with LuminX or other claims systems

Claim audit or extensive claim processing experience required

Ability to demonstrate excellent communication skills both verbally and written and foster productive working relationships

Organizational skills to perform detail-oriented tasks and balance a variety of responsibilities both independently and as part of a team

Strong analytical, judgement/critical thinking and problem-solving skills

Experience with Microsoft Office Suite products

Ability to prioritize tasks and projects to meet deadlines

Preferred

Data mining/query/process flow tools (e.g., Access, SQL, ACL, Visio)

Life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

Wellfleet

Accident and health insurance for education and workplace markets.

Claims audit experience LuminX claims processing Medical terminology Data mining tools Microsoft Office Suite