Precision Healthcare Claims QA Specialist

Cobalt Benefits Group LLC; Portsmouth (NH); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Medical insurance

401(k) retirement plan

Paid holidays

Paid time off

Job summary

Cobalt Benefits Group is seeking a detail-oriented Healthcare Claims Quality Assurance Specialist to support our healthcare vertical clients through comprehensive claims auditing and quality oversight. This role involves daily audits of medical claims to help ensure accurate benefit administration, provider network tiering, and contract pricing.

The position requires 3+ years of health insurance claims processing experience and strong analytical skills.

Qualifications

• Associate degree or equivalent with 3+ years claims processing/adjudication experience.
• Strong understanding of medical claims adjudication and benefit administration.
• Experience reviewing provider contracts, pricing methodologies, and network structures.
• Proficient in Microsoft Office (Excel, Word, Outlook, Teams).
• Excellent written and verbal communication; able to work independently.

Responsibilities

• Perform daily pre-pay and post-pay audits of medical claims.
• Review and audit medical claims for accuracy per member benefits and contracts.
• Validate benefit application including deductibles, copays, coinsurance, eligibility, and plan provisions.
• Audit provider network tiering and reimbursement accuracy.
• Verify claims processing aligns with contracts, fee schedules, and client plans.
• Identify, document, and communicate claim processing errors and trends.
• Conduct production, system configuration, and operational quality audits.
• Complete LDLA and MTM reviews.
• Support external client, regulatory, and internal audit activities.
• Participate in new client, renewal, and plan change testing.
• Produce audit reports and recommend corrective actions and process improvements.
• Collaborate with Claims, Provider Maintenance, Customer Service, Configuration and Implementation teams.

Skills

Health insurance claims processing

Provider contracts review

Analytical skills

Microsoft Office

Communication skills

Independent work

Self-funded health plans

TPA environments

Blue Cross Blue Shield

Javelina

Provider network tiering

Problem solving

Education

Associate degree or equivalent combination of education and experience

Tools

Javelina

Job description

Cobalt Benefits Group is seeking a detail-oriented Healthcare Claims Quality Assurance Specialist to support our healthcare vertical clients through comprehensive claims auditing and quality oversight. This role involves daily audits of medical claims to help ensure accurate benefit administration, provider network tiering, and contract pricing.

The position requires 3+ years of health insurance claims processing experience and strong analytical skills.