Healthcare Claims Quality Analyst

📋 Description

• • Evry Health is at the forefront of revolutionizing health insurance by injecting humanity into a system often perceived as impersonal and complex. We are dedicated to creating high-technology health plans that not only expand benefits and increase access but also champion transparency and a personalized, human-centered approach. Our ultimate goal is to empower our members to lead happier, healthier lives. As a key player in this mission, Evry Health, the major medical division of Globe Life (NYSE: GL), is seeking a highly motivated and detail-oriented Healthcare Claims Quality Analyst to join our dynamic remote operations team.
• • In this critical role, you will be instrumental in upholding the integrity and accuracy of our medical claims processing. You will conduct in-depth audits of medical claims, meticulously scrutinizing them to ensure impeccable payment accuracy, unwavering healthcare compliance, and strict adherence to all applicable plan benefits and industry regulations. This fully remote position offers the unique opportunity to dive deep into the intricacies of complex medical claims, disputes, payment adjustments, and adjudication decisions, directly impacting member satisfaction and provider trust.
• • Your primary responsibility will be to perform comprehensive quality audits, serving as a guardian of our claims processing standards. This involves a deep dive into the adjudication process, identifying any discrepancies, errors, or areas for improvement. You will become a subject matter expert in medical claims adjudication and claims processing guidelines, using this knowledge to evaluate the performance of our Claims Analysts and the accuracy of payments made. Your insights will be crucial in identifying root causes of errors and recommending corrective actions.
• • A significant aspect of this role involves collaborating closely with the Vice President of Operations to develop and formalize our audit program. This includes defining appropriate statistical sample sizes for audits, establishing robust quality results reporting mechanisms, creating employee scorecards to track individual performance, and developing a comprehensive error taxonomy for consistent classification. Your contributions will shape the very framework of our quality assurance efforts.
• • You will be responsible for a wide range of quality assurance activities designed to maintain service excellence and drive continuous improvement in claim accuracy. This includes proactively identifying trends in claims processing errors, proposing essential documentation updates, suggesting workflow enhancements, and recommending changes to optimize the claims processing experience for both internal teams and external stakeholders. Your analytical skills will be key in pinpointing opportunities for efficiency and accuracy gains.
• • Reporting on your findings will be a core function. You will report out audit results to the relevant employees, providing constructive feedback and identifying areas for development. Furthermore, you will summarize weekly performance metrics into comprehensive monthly reports, highlighting key performance indicators, top error trends, and actionable recommendations for closing any identified gaps. This reporting will be vital for informing strategic decisions and driving accountability.
• • A crucial part of your role will be to follow up on identified errors, ensuring that claims are corrected accurately and efficiently before final payment is issued. You will also develop and implement a rebuttal process to ensure that any identified errors are appropriately assigned and addressed, fostering a fair and transparent review system. This ensures that our commitment to accuracy is maintained throughout the entire claims lifecycle.
• • The ideal candidate will possess a strong analytical mindset, exceptional problem-solving abilities, and an unwavering commitment to accuracy. You should be comfortable working independently in a fast-paced, deadline-oriented remote environment, while also being a collaborative team player. Your ability to articulate complex topics clearly, both verbally and in writing, will be essential when communicating findings and recommendations to various levels of the organization, including senior leadership.
• • This role is specifically focused on healthcare claims auditing for medical claim accuracy and compliance. It is distinct from software testing or IT quality assurance roles. You will be expected to partner with senior leadership on a daily basis, providing critical insights that influence operational strategies and quality standards. Your expertise will directly contribute to Evry Health's mission of bringing humanity to health insurance and ensuring our members receive the highest level of service and accuracy in their healthcare claims.