Quality Specialist Jobs

About The Position

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.