Claims Quality Assurance Analyst - TPA

Network Health WI•Menasha, WI

4d•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 identifies trends, inefficiencies, and improvement opportunities, and ensures adherence to quality standards, regulatory and contractual requirements, and operational procedures. The role also performs internal audit activities and supports Internal Audit with Model Audit Requirements (MAR), Service Level Agreements (SLAs), and other applicable audit and compliance standards. The Analyst analyzes findings and operational data to identify root causes, recommend corrective actions, and contribute to continuous improvement. The position works with subject matter experts and cross-functional partners to investigate and resolve complex claims payment and processing issues. It applies and interprets company 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 subject matter 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 position follows a hybrid workplace model, combining work from a home office with work at the office; reliable home internet is required. The schedule is 1.0 FTE, 40 hours per week, 8 a.m.–5 p.m., Monday through Friday.

Requirements

High school diploma or equivalent.
At least 2 years of experience working in an auditing or claim payment accuracy-focused role.
At least 2 years of health care experience.

Responsibilities

Demonstrate 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 in accordance with established criteria, methodologies, 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 established 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 audits and monitoring; request and coordinate custom claims reports as needed.
Support SLA-related claims audits and monitoring, track results, and identify opportunities to improve compliance and performance.
Assist Internal Audit with applicable MAR functions through 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 strong 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.