Quality Assurance Specialist - Medical Claims

• Develop and maintain a thorough understanding of quality expectations, performance standards, policies, procedures, and compliance requirements related to medical claims processing.

• Develop and maintain a thorough understanding of quality expectations, performance standards, policies, procedures, and compliance requirements related to medical claims processing.
• Monitor and evaluate processor performance through quality audits and transaction reviews, providing objective feedback and identifying opportunities for improvement.
• Partner with supervisors and operational leaders to support performance improvement initiatives and corrective action plans.
• Conducts performance improvement coaching's based on quality results
• Assists all new hire classes on QA requirements/expectations
• Analyze quality data and prepare regular reports that highlight trends, areas of risk, and opportunities for process enhancement.
• Publish and communicate quality performance metrics to management and project stakeholders on a regular basis.
• Maintain accurate records of quality reviews, audit findings, corrective actions, and identified issues.
• Support internal and external audit readiness activities, including documentation reviews and compliance assessments.
• Collaborate with Training, Compliance, and Operations teams to investigate quality concerns and implement effective solutions.
• Participate in calibration sessions and quality review meetings to ensure scoring consistency and alignment across teams.

• High school diploma or equivalent required; associate's or bachelor's degree preferred.
• Minimum of 3 years of quality assurance, quality control, auditing, or process improvement experience.

• At least 1 year of experience in a healthcare, medical claims processing, or related operational environment preferred.

• At least 1 year of experience in a healthcare, medical claims processing, or related operational environment preferred.
• Experience auditing healthcare operations, medical claims processing, eligibility verification, prior authorizations, or related healthcare transactions preferred
• Experience conducting quality audits, analyzing performance data, and driving process improvement initiatives.
• Prior experience in a business process outsourcing (BPO), customer operations, healthcare services, or similar environment is preferred.
• Working knowledge of quality management principles, audit methodologies, and continuous improvement practices.
• Strong analytical and problem-solving skills with the ability to identify trends, root causes, and opportunities for improvement.
• Excellent written and verbal communication skills, including the ability to provide constructive feedback and present findings to stakeholders.
• Strong attention to detail and ability to maintain accuracy while managing multiple priorities.
• Proficiency with Microsoft Excel and reporting tools used to track, analyze, and communicate quality performance metrics.
• Ability to collaborate effectively with cross-functional teams, including Operations, Training, and Compliance.
• Ability to adapt to changing business needs and work effectively in a fast-paced environment.

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources
• $19.44 per hour