Senior Claims Quality Analyst

Job Summary

Focused on enhancing claims accuracy and operational excellence, the full-time Senior Claims Quality Analyst will conduct in-depth audits of complex claims, collaborate with various teams, and drive the implementation of automated solutions in a remote work environment.

Key responsibilities

• Conduct in-depth audits and clinical reviews of high-dollar claims to ensure adjudication accuracy and compliance with health plan policies
• Utilize advanced coding expertise to substantiate audit findings and investigate potential fraud and utilization patterns
• Identify trends and operational risks impacting claims quality, developing reports and recommendations for leadership

Required qualifications

• BA/BS degree in a related field
• Minimum 5 years of experience in healthcare claims auditing or coding auditing
• Current certification from AAPC or AHIMA (e.g., RHIA, RHIT, CCS, CIC, CPC)
• Experience with ICD-10CM, MS-DRG, AP-DRG, and APR-DRG coding standards
• Strong analytical and investigative skills