Quality Assurance Specialist

Position Summary

The Quality Assurance Specialist is responsible for auditing and adjusting all healthcare claims to ensure accuracy, completeness, and compliance with internal policies and external regulatory requirements.

This role enhances operational effectiveness by identifying training needs and recommending process improvements.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities


* Assists with the auditing and adjustments of all types of claims.


* Ensures the completion and submission of all required audit reports to management.


* Analyzes and identifies training needs based on audit results and system issues.


* Reviews and adjust a wide variety of claims to ensure accuracy, completeness, and compliance with established policies and procedures.


* Provides backup support for various claims processing and customer service functions as needed.


* Identifies potential problems or trends in processes and recommends changes for management review.


* Identifies potential issues and recommends solutions to improve processes.


* Complies with departmental quality standards and error ratio guidelines as outlined in the Production and Error Ratio policies.


* Seeks opportunities to deliver the highest quality of service by actively listening and communicating effectively with participants, colleagues, clients, employers, and vendors.


* Excels in a collaborative team environment while working independently with minimal supervision.


* Assists participants, co-workers, clients, employers, and vendors by answering inquiries via phone, in-person, or email in a friendly, courteous, and professional manner.


* Analyzes audit results and claims data to identify patterns, recurring issues, and opportunities for operational improvements; prepares concise reports for management review.


* Collaborates with management and cross-functional teams to implement approved process improvements based on audit findings and operational trends.


* Performs other duties as assigned.

Minimum Qualifications


* High School Diploma or GED.


* One-Two years of experience as a Claims Examiner, Customer Service Representative (CSR), or in specialized roles within the department.


* Strong knowledge of interpreting Plan Documents including Eligibility, Exclusions, and Limitations.


* Possess a strong understanding of CPT, ICD-10, and HCPCS coding.


* Extensive knowledge of claims processes and customer service systems.


* Proficient in Microsoft Word, Outlook, Excel, and basic database management.


* Proficient in company software, including Contribution Accounting System, Encounter Tracking, Claims System, and Electronic Reference.


* Ability to effectively prioritize tasks, manage multiple responsibilities simultaneously, and perform well in a fast-paced, dynam...