Claims Quality Specialist

Overview

Responsibilities

The Claims Quality Specialist is responsible for ensuring the accuracy and quality of claims processing within a managed care service organization. This role involves auditing claims, identifying errors, and implementing corrective actions to improve overall claims accuracy and efficiency. The Claims Quality Specialist will work closely with the Claims Research colleague and other team members to enhance claims processes and ensure compliance with regulatory standards.

Qualifications

Minimum Qualifications:

• Minimum of 5 years of experience in claims processing, quality assurance, or a related role within a managed care or healthcare environment.
• Strong knowledge of healthcare claims processing, coding (ICD-10, CPT, HCPCS), and billing practices
• Proficiency in using a managed care and/or claims processing platform.
• High School Diploma or equivalent required

Preferred Qualifications:

• Experience with data analytics tools and software such as SQL, SAS
• Previous experience working directly with healthcare providers or within a provider network setting
• Bachelor’s Degree – Bachelor’s degree in Business, Healthcare Administration, or a related field