Sr. Claims Integrity & Quality Analyst, Health Plan Operations

Senior Claims Integrity & Quality Analyst

At Curative, we're challenging the status quo in healthcare by removing barriers to care and creating a health plan experience that is transparent, proactive, and built around member health outcomes. As we continue to scale nationally, we're looking for a Senior Claims Integrity & Quality Analyst who is passionate about improving claims accuracy, reducing operational friction, and helping build a modern, technology-enabled claims organization. This is not a traditional audit role. You'll help design and execute the quality framework that drives payment accuracy, regulatory compliance, automation, and operational excellence across our claims ecosystem. You'll partner with Claims Operations, Configuration, Product, Compliance, and Technology teams to identify root causes, eliminate defects, and improve auto-adjudication performance. If you enjoy solving complex problems, improving systems, and influencing operational outcomes, we'd love to meet you.

This key role is responsible for conducting in-depth analysis of high-dollar and complex claims, including IDR's, and Balance Billing scenarios, to ensure the supporting medical documentation validates the billing received for payment. This role is critical in driving solutions for first pass claims payment accuracy. Collaborate with payment integrity to ensure compliance with commercial health plan policies, contract agreements, and industry regulations.

How you will make an impact:

• Conduct in-depth audits and clinical reviews of professional, institutional, ancillary, and high-dollar claims, focusing on adjudication accuracy, benefit application, pricing, and coding (ICD-10, CPT/HCPCS, DRG).
• Utilize advanced coding expertise and workflow systems to substantiate audit findings, generate recoverable claims, and investigate potential fraud and utilization patterns.
• Drive operational excellence by validating claims configuration, reimbursement methodologies, and processing logic.
• Support the implementation of automated controls, advanced editing/AI solutions, and workflow enhancements to improve payment accuracy, reduce administrative costs, and contribute to the development of audit tools, policies, and procedures.
• Identify trends, defects, and operational risks impacting claims quality. Develop reports and present findings and recommendations to operational leadership to drive corrective actions and improvement opportunities.

Minimum Requirements:

• BA/BS degree in a related field
• Minimum 5 years of experience in healthcare claims auditing, coding auditing, or formal quality assurance program experience. Broad knowledge of provider billing guidelines, payer reimbursement policies, medical policy guidelines, and commercial insurance plans.
• Requires at least one of the following current certifications from AAPC or AHIMA: RHIA, RHIT, CCS, CIC, or CPC.
• Minimum 5 years of experience working with ICD-10CM, MS-DRG, AP-DRG, and APR-DRG coding standards.
• Experience identifying root causes and driving corrective actions.
• Strong analytical and investigative skills.

Preferred Skills, Capabilities and Experience:

• Health plan or payer-side experience
• Experience with claims configuration validation
• Experience supporting automation initiatives
• Experience working in a high-growth environment
• Clinical nursing with exposure to hospital bill auditing.
• Unrestricted Registered Nurse (RN) license.
• Proficiency in Google Workspace and experience with audit tracking systems and data analytics tools (Snowflake, Streamlit, Claude).

Perks & Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
• $0 copays and $0 deductibles (with completion of our Baseline Visit )
• Preventive and primary care built in
• Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged)
• One-on-one care navigation
• Chronic condition programs (diabetes, weight, hypertension)
• Maternity and family planning support
• 24/7/365 Curative Telehealth
• Pharmacy benefits
• Comprehensive dental and vision coverage
• Employer-provided life and disability coverage with additional supplemental options
• Flexible spending accounts
• Flexible work options: remote and in-person opportunities
• Generous PTO policy plus 11 paid annual company holidays
• 401K for full-time employees
• Generous Up to 812 weeks paid parental leave, based on role eligibility.