Claims Quality Business Analyst

• Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements.
  • Remittance Advice (RA)
  • Denial Letters/IDN
  • Explanation of Benefits (EOB)
• Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes.
• Identify trends related to pended, denied, adjusted, and overturned claims.
• Develop and maintain claims quality monitoring reports and dashboards.
• Ensure claims communications accurately communicate payment decisions, denial rationale, member responsibility, provider responsibility, and applicable benefit or payment explanations.

Business Analysis

• Gather business requirements for system enhancements and claims operational improvements.
• Analyze claims workflows and recommend process improvements to increase efficiency and reduce rework.
• Collaborate with IT, Delegates and providers/vendors on claims system configuration, testing, and implementation activities.
• Perform data validation and user acceptance testing (UAT) for claims-related system changes.

Regulatory and Compliance Support

• Evaluate claims operations for compliance with CMS Medicare Advantage requirements, AHCA requirements, and internal policies.
• Lead implementation of regulatory, benefit, and operational changes affecting RA/EOB content, claims reason codes, remark codes, notices, and member/provider-facing explanations.
• Assist with audit readiness activities, CAP development, and monitoring of corrective actions.

Reporting and Analytics

• Develop reports tracking:
  • Metrics/Claims turnaround time (TAT)
  • Auto-adjudication rates
  • Financial accuracy
  • Denial trends
  • Encounter submission quality/reporting
  • Claims Adjudicator Production
• Present findings and recommendations to leadership

• Partner with IT, Quality, Compliance, Medical Management, Provider Relations, and Member Services teams.
• Participate in operational committees and quality improvement initiatives.
• Assist with provider and internal staff education related to claims processes and regulatory requirements.

• Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field.
• 3–5 years of health plan claims operations, business analysis, or healthcare analytics experience.
• Experience with Medicare Advantage, Medicaid, or managed care claims processing.
• Strong analytical and reporting skills.

Preferred

• Experience working with claims platforms (Facets, QNXT, HealthRules, or similar).
• Experience supporting CMS audits and regulatory compliance activities.
• Knowledge of encounter data reporting and MA organization requirements.
• Lean Six Sigma or process improvement experience.
• Knowledge of Medicare Advantage claims payment methodologies.
• Understanding of claims adjudication and provider reimbursement concepts.
• Advanced Excel and data analysis skills.
• Ability to analyze large data sets and identify operational trends.
• Strong verbal and written communication skills.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.