Quality Assurance Specialist
About The Position
Cobalt Benefits Group is seeking a detail-oriented Quality Assurance Specialist to support our healthcare vertical clients through comprehensive claims auditing and quality oversight. This role is primarily responsible for conducting daily audits of medical claims to ensure accurate benefit administration, correct provider network tiering, and appropriate contract pricing. The Quality Assurance Specialist plays a critical role in maintaining payment accuracy, identifying process improvement opportunities, and supporting operational excellence across Claims & Service Operations.
Requirements
- Associate degree or equivalent combination of education and experience.
- 3+ years of health insurance claims processing, auditing, or quality assurance experience.
- 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.
- 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 LDLA (Licensee Desk Level Audit) and MTM (Member Touchpoint Measurement) 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
- Fantastic medical, dental, and vision insurance
- Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible!
- Company provided Basic Life and AD&D
- Company paid Short-Term and Long-Term Disability
- Flexible Spending Accounts
- 401(k) Retirement Plan with up to a 6% employer-match
- 10+ paid holidays
- Fully Paid half day Summer Fridays
- Generous paid vacation and sick time
- Annual Paid Volunteer Day
- Annual Tuition Reimbursement
- Annual Health and Wellness Reimbursement
- Lots of fun company events
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
