Remote Claims Quality & Compliance Analyst

Network Health; Town of Brookfield (WI); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Network Health is seeking a Claims Quality Assurance Analyst - TPA to support operational excellence, ensure claims accuracy, and uphold regulatory compliance. The role conducts quality audits, reviews claims and data, and identifies trends for process improvements to deliver high-quality services to members and providers.

The position collaborates with cross-functional teams, applies reimbursement policies and regulatory standards, and participates in MAR, SLAs, and other audit activities.

Qualifications

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

Responsibilities

• Demonstrate commitment to Network Health's mission and values.
• Apply organizational, regulatory, contractual, and procedural requirements.
• Perform data entry, claims, enrollment, and monitoring activities.
• Review medical claims and records for completeness and accuracy.
• Conduct claims quality audits and monitoring to identify discrepancies and trends.
• Analyze results to identify root causes and recommend improvements.
• Document and communicate audit findings to leadership and teams.
• Ensure monitoring and audit activities are completed accurately and timely.
• Maintain tracking databases and audit tools for quality reporting.
• Run daily claims inventory reports for audits and monitoring.
• Support SLA-related audits and compliance efforts.
• Assist MAR-related functions with audits and documentation.
• Review Desk Level Procedure documents to reflect current practices.
• Collaborate with SMEs to resolve quality issues and ensure accurate payments.
• Maintain professional relationships and support department goals.
• Identify opportunities to improve claims processes and efficiency.

Skills

Auditing

Claims review

Data analysis

Tools

Microsoft Excel

SQL

Job description

Network Health is seeking a Claims Quality Assurance Analyst - TPA to support operational excellence, ensure claims accuracy, and uphold regulatory compliance. The role conducts quality audits, reviews claims and data, and identifies trends for process improvements to deliver high-quality services to members and providers.

The position collaborates with cross-functional teams, applies reimbursement policies and regulatory standards, and participates in MAR, SLAs, and other audit activities.