Quality Analyst - Medical Claims

The QA Associate is responsible for conducting accurate reviews and audits of medical claims based on established claims processing guidelines, policies, and procedures. The role requires proficiency in applicable product lines and ensures that claims are processed accurately, efficiently, and in compliance with quality standards.

Key Responsibilities:

• Review and audit processed medical claims to ensure accuracy and compliance with applicable guidelines and policies
• Analyze claim decisions and determine whether the approval or denial actions taken by claims processors are appropriate
• Verify that accurate payment criteria and adjudication rules were applied when clearing pending claims
• Research claim edits and benefit applications to ensure compliance with established criteria and applicable policies
• Review physician contract pricing applications and confirm accuracy of claim processing activities
• Evaluate provider inquiries related to claim adjudication and ensure they have been properly reviewed and resolved
• Apply knowledge of medical coding, medical terminology, and healthcare claims forms throughout the audit process
• Perform high-volume claim audits while maintaining accuracy and quality standards
• Meet productivity targets and quality metrics as established by the business
• Identify process deviations and provide feedback to support continuous quality improvement initiatives
• Ensure compliance with HIPAA regulations and organizational policies in all claim review activities

• Bachelor's Degree in any field
• Professional certification or credentials related to healthcare, claims processing, coding, or quality assurance an advantage

• At least 2 years of experience in medical claims processing
• Prior Quality Assurance (QA) experience in claims processing is required
• Experience in medical coding, including diagnosis coding and healthcare terminology, is an advantage

• Strong knowledge of U.S. Healthcare practices and medical claims adjudication
• Ability to multitask and follow documented claims processes with minimal supervision.
• Excellent verbal and written communication skills
• Strong proficiency in Microsoft Office applications, particularly Microsoft Excel
• High attention to detail and strong analytical and decision-making skills
• Good understanding of QA metrics, KPIs, and performance standards
• Ability to work effectively in a fast-paced, high-volume environment