Senior Claims Quality Assurance Analyst

Neighborhood Health Plan of Rhode Island; Smithfield (RI); On-site; USD 55,000 - 75,000; Full time

Job summary

Neighborhood Health Plan of Rhode Island is seeking a Claims Quality Control Auditor to ensure claims processing aligns with contractual and regulatory requirements. The role involves auditing both internal and external processes, producing statistical reports, and driving improvements to accuracy and provider satisfaction.

Responsibilities include reviewing auto and manual claims, identifying trends, and presenting findings to management.

Qualifications

• Experience in medical billing or claims processing.
• Ability to read and apply contract terms to claims processing and quality audits.
• Proficient in data analytics and Excel for reporting.

Responsibilities

• Review claim processing functions against provider and health plan contracts.
• Identify trends and errors, prepare written audit reports.
• Assist with root cause analysis and corrective actions.
• Participate in UAT and system upgrade reviews to ensure accuracy.
• Report suspected fraud, waste, or abuse as required.

Skills

Medical billing

Data analytics

Excel

Communication

Teamwork

Education

Associates Degree or equivalent

Tools

Cognos

Optum Encoder

Job description

Neighborhood Health Plan of Rhode Island is seeking a Claims Quality Control Auditor to ensure claims processing aligns with contractual and regulatory requirements. The role involves auditing both internal and external processes, producing statistical reports, and driving improvements to accuracy and provider satisfaction.

Responsibilities include reviewing auto and manual claims, identifying trends, and presenting findings to management.