Healthcare Claims Quality Assurance Specialist

Cobalt Benefits Group LLC•South Burlington, VT

5d•$45,000 - $51,000

About The Position

Cobalt Benefits Group is seeking a detail-oriented Quality Assurance Specialist to support healthcare clients through comprehensive claims auditing and quality oversight. The role conducts daily medical-claim audits to help ensure accurate benefit administration, provider network tiering, and contract pricing. It supports payment accuracy, identifies process improvement opportunities, and promotes operational excellence across Claims & Service Operations.

Requirements

Associate degree or equivalent combination of education and experience.
At least 3 years of hands-on health insurance claims processing or adjudication experience, including reviewing medical claims for accuracy and applying benefit provisions.
Strong understanding of medical claims adjudication and benefit administration.
Experience reviewing provider contracts, pricing methodologies, and network structures.
Advanced analytical, organizational, and problem-solving skills.
Proficiency with Microsoft Office, including Excel, Word, Outlook, and Teams.
Excellent written and verbal communication skills.
Ability to work independently while managing multiple priorities.

Nice To Haves

Experience with self-funded health plans and healthcare TPA environments.
Knowledge of Blue Cross Blue Shield processes and standards.
Experience with Javelina or similar claims administration systems.
Understanding of provider network tiering and implementation testing.

Responsibilities

Perform daily pre-pay and post-pay audits of medical claims.
Review claims for accurate processing in accordance with member benefits, provider contracts, fee schedules, and plan requirements.
Validate benefit application, including deductibles, copays, coinsurance, eligibility, and plan provisions.
Audit provider network tiering and reimbursement accuracy.
Verify claims are processed according to provider contracts, fee schedules, and client plan designs.
Identify, document, and communicate claim-processing errors and trends.
Conduct production, system configuration, and operational quality audits.
Complete Licensee Desk Level Audit (LDLA) and Member Touchpoint Measurement (MTM) reviews.
Support external client, regulatory, and internal audit activities.
Participate in new-client, renewal, and plan-change testing efforts.
Produce audit reports and recommend corrective actions and process improvements.
Collaborate with Claims, Provider Maintenance, Customer Service, Configuration, and Implementation teams to resolve quality issues.

Benefits

Medical, dental, and vision insurance for eligible full-time employees after a waiting period.
Twice-annual employer HSA contributions covering 50% of the HDHP plan’s annual deductible.
Company-provided basic life and AD&D insurance.
Company-paid short-term and long-term disability.
Flexible Spending Accounts.
401(k) retirement plan with up to a 6% employer match, fully vested after 3 years.
10 or more paid holidays.
Fully paid half-day Summer Fridays.
Paid vacation and sick time.
Annual paid volunteer day.
Annual tuition reimbursement.
Annual health and wellness reimbursement.
Company events.