Claims Quality Assurance Analyst - TPA

Menasha•Menasha, WI

3d•Hybrid

About The Position

The Claims Quality Assurance Analyst – TPA supports operational excellence, claims accuracy, and regulatory compliance by conducting quality audits, reviews, and monitoring of claims and operational data. The Analyst ensures adherence to quality standards, regulatory and contractual requirements, and operational procedures, and supports accurate, efficient, and consistent claims processing. The position also performs internal audit activities and supports Internal Audit requirements related to Model Audit Requirements (MAR), Service Level Agreements (SLAs), and other applicable audit and compliance standards. The Analyst analyzes audit findings and operational data to identify trends, root causes, inefficiencies, and opportunities for improvement, and recommends corrective actions. The role collaborates with subject matter experts and cross-functional partners to investigate and resolve complex claims payment and processing issues. It applies and interprets reimbursement policies, Desk Level Procedures (DLPs), Summary Plan Descriptions (SPDs), Administrative Services Agreements (ASAs), CMS regulations, provider contracts, and other applicable resources to determine appropriate claims payment outcomes. As a resource for claims quality and accuracy, the Analyst helps strengthen processes, reduce errors, improve operational performance, and maintain compliance. Candidates must reside in Wisconsin. The role uses a hybrid workplace model, combining work from a home office (reliable internet required) with work at the office. The position is 1.0 FTE, 40 hours per week, 8 a.m.–5 p.m., Monday through Friday. Employees may volunteer in their local neighborhood while being paid.

Requirements

High school diploma or equivalent.
At least 2 years of experience in an auditing or claims payment accuracy-focused role.
At least 2 years of experience in health care.
Must reside in Wisconsin.
Reliable internet is required for working from a home office.

Responsibilities

Demonstrate commitment to and behavior aligned with Network Health’s philosophy, mission, values, and vision.
Apply organizational, regulatory, contractual, and operational principles, procedures, requirements, regulations, and policies appropriately.
Perform data entry, claims, enrollment, and operational monitoring activities according to established criteria, methods, and timelines.
Review medical claims, supporting documentation, and medical records, as applicable, for completeness, accuracy, appropriate payment, and compliance.
Conduct claims quality audits and monitoring to identify payment discrepancies, processing errors, trends, and opportunities to improve accuracy, efficiency, and consistency.
Analyze audit and operational results to identify trends and root causes and develop actionable process-improvement recommendations.
Document and communicate audit and monitoring results, including discrepancies, trends, risks, and recommended corrective actions, to leadership and appropriate team members.
Complete monitoring and audit activities accurately and on time according to schedules, standards, and requirements.
Maintain tracking databases, audit tools, documentation, and files for quality monitoring and reporting.
Run, review, and compile daily claims inventory reports for audit and monitoring activities, and request and coordinate custom claims reports as needed.
Support claims audits and monitoring related to SLAs, track results, and identify opportunities to improve compliance and performance.
Assist Internal Audit with applicable MAR functions by performing assigned audit, monitoring, research, documentation, and reporting activities.
Review DLP documents and provide feedback to help ensure they reflect current claims processing practices, requirements, and processes.
Research and collaborate with subject matter experts and internal departments to resolve claims quality issues and determine appropriate payment outcomes.
Maintain effective working relationships with internal and external contacts and demonstrate professionalism, accountability, adaptability, and commitment to service.
Support department initiatives, projects, teammates, and overall department goals and objectives.
Identify and communicate opportunities to improve claims processes, quality, accuracy, and operational efficiency.