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Healthcare Claims Quality Analyst

1 month ago
United States
Full-time
Mid Level
QA Engineer
Quality Assurance and Testing
HIPAA Salesforce
Apply Now
Evry Health

Evry Health

Evry Health is a modern health insurance company that prioritizes delivering great benefits at affordable prices. They offer a unique approach to health insurance by focusing on making members healthier and happier through personalized care from a dedi...

Insurance
11-50
Founded 2017
$7M raised
View All Jobs 2

Description

  • Develop and formalize the audit program, including statistical sample sizes, error taxonomy, employee scorecards, and quality results reporting.
  • Perform in-depth audits of complex medical claims, disputes, payment adjustments, and adjudication decisions to ensure payment accuracy and compliance with plan benefits and regulations.
  • Become a subject matter expert in medical claims adjudication and processing guidelines to evaluate Claims Analyst performance and payment accuracy.
  • Create and deliver regular KPI and quality reports (weekly and monthly) summarizing results, top error trends, and recommendations to close gaps.
  • Follow up on identified errors to ensure claims are corrected prior to check runs and develop a rebuttal process to appropriately assign errors.
  • Propose and drive documentation updates, workflow improvements, and training opportunities based on audit findings and trend analysis.
  • Collaborate with business and operational units and partner with senior leadership (reports to VP of Operations) to communicate results and implement improvements.
  • Design and maintain QA reporting and tracking mechanisms to allow easy identification of trends, training needs, and quality issues.

Requirements

  • 3–5 years of commercial health plan experience.
  • 2–3 years of experience performing claims auditing or quality review functions.
  • Expertise in medical claims adjudication and healthcare claims processing.
  • Familiarity with healthcare compliance requirements and claim processing regulations.
  • Solid knowledge of medical and insurance industry terminology.
  • Excellent verbal and written communication skills with the ability to explain complex topics to broad audiences.
  • Strong attention to detail, problem-solving skills, and a high level of accuracy in a fast-paced, deadline-oriented environment.
  • Proficiency with Microsoft Office applications (Word, Excel, Outlook, OneNote) and prior CRM experience, preferably Salesforce.
  • Must reside in the United States within the Eastern or Central (EST/CST) time zones, be available during company business hours (weekdays, 9–5 CST), and be comfortable partnering with senior leadership daily.
  • Remote-work requirements: dedicated private work area, ability to secure company sensitive documents, and access to reliable high-speed internet.
  • Note: this role focuses on healthcare claims auditing (medical claim accuracy and compliance), not software/IT quality assurance.

Benefits

  • Competitive salary.
  • Comprehensive health, dental, and vision insurance plus life and disability coverage.
  • Retirement savings plan with company match.
  • Generous time off / vacation.
  • Professional development opportunities.
  • Flexible, fully remote work environment.

Interested in this position?

Apply directly on the company website

Apply Now

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