Quality Assurance Specialist - Healthcare Payer Industry

Smart Data Solutions; Plano (TX); Hybrid; USD 60,000 - 70,000; Full time

Job summary

Ein innovatives Unternehmen im Gesundheitswesen sucht einen Quality Assurance Specialist, der sich leidenschaftlich für die Verbesserung von Prozessen und die Gewährleistung von Qualität einsetzt. In dieser hybriden Rolle arbeiten Sie eng mit verschiedenen Teams zusammen, um komplexe Audits durchzuführen und sicherzustellen, dass alle Abläufe den höchsten Standards entsprechen. Sie werden die Möglichkeit haben, Ihre Fähigkeiten in einem dynamischen Umfeld weiterzuentwickeln, während Sie zur digitalen Transformation und Kostensenkung beitragen. Wenn Sie eine proaktive Person sind, die gerne in einem kollaborativen Team arbeitet, ist dies die perfekte Gelegenheit für Sie.

Benefits

Gesundheitsversicherung

Invaliditätsversicherung

401(k) Matching

Großzügige PTO

Qualifications

• Mindestens 3 Jahre Erfahrung in der Qualitätssicherung oder im Auditbereich im Gesundheitswesen.
• Starkes Verständnis der Gesundheitsvorschriften und Compliance-Anforderungen.

Responsibilities

• Durchführung komplexer Qualitätsprüfungen und Entwicklung von Auditprogrammen.
• Zusammenarbeit mit Entwicklern und Produktmanagern zur Verbesserung der Produktqualität.

Skills

Qualitätskontrolle

Datenanalyse

Kommunikationsfähigkeiten

Detailorientierung

Multitasking

Education

Bachelor in Betriebswirtschaft

Bachelor in Gesundheitsverwaltung

Tools

Microsoft Excel

Microsoft Word

Microsoft PowerPoint

Job description

Quality Assurance Specialist - Healthcare Payer Industry

Join to apply for the Quality Assurance Specialist - Healthcare Payer Industry role at Smart Data Solutions.

Job Overview

Smart Data Solutions, a leading provider of data management, claim routing, and workflow solutions to health plans and TPAs, is seeking a Quality Assurance Specialist to join our team.

Salary Range

$60,000.00/yr - $70,000.00/yr. Actual pay will depend on skills and experience; discuss with your recruiter.

Responsibilities

• Analyze business specifications and requirements; liaise with clients and internal teams.
• Handle diverse issues, evaluating current business trends.
• Conduct complex transactional quality audits.
• Develop, implement, and maintain comprehensive quality audit programs.
• Perform quality audits on administrative operations supporting client services.
• Analyze escalated business process issues; recommend improvements.
• Identify, document, and report defects during testing.
• Collaborate with developers, product managers, and stakeholders to enhance product quality.
• Create and execute detailed test plans and strategies.
• Oversee audit assessments to ensure policy and procedure conformance.
• Lead corrective action initiatives to improve operations and accuracy.
• Support root cause analysis and maintain corrective action plans.
• Analyze data/metrics to identify trends and escalate issues as needed.
• Participate in external audits and inspections.
• Perform additional duties as assigned.

Qualifications

• Bachelor’s degree in Business Administration, Healthcare Administration, or related field; equivalent experience considered.
• At least 3 years of experience in quality assurance or auditing within healthcare.
• Strong understanding of healthcare regulations and compliance.
• Experience conducting audits and preparing reports with actionable insights.
• Ability to analyze data to identify discrepancies and noncompliance.
• Proficiency in Microsoft Office, especially Excel, Word, PowerPoint.
• Experience reviewing medical claim forms (HCFA, CMS-1500, UB-04, ADA).
• Knowledge of claims processing, prior authorization workflows, denials, and appeals.
• Familiarity with ICD-10, HCPCS, CPT, modifiers.
• Excellent communication skills; ability to present complex findings clearly.
• Detail-oriented with strong multitasking abilities.
• Ability to work independently and in a team.
• Experience with EDI, 837/835 files, X12 standards is a plus.

Location & Work Environment

This hybrid role is based in Dallas (Plano, TX), requiring 3 days in-office per week.

Why Join Us?

• Innovative, collaborative culture emphasizing professional growth.
• Comprehensive benefits including health insurance, disability coverage, 401(k) match, and generous PTO.

About Smart Data Solutions

We are a leader in healthcare process automation and interoperability, serving over 500 clients including Blue Cross Blue Shield plans and regional health plans. We focus on digital transformation to reduce costs and improve customer experience.

Equal Opportunity Employer

Smart Data Solutions is committed to diversity and inclusion. All qualified applicants will receive consideration regardless of race, color, sex, sexual orientation, gender identity, religion, or other protected status.