Healthcare Claims Quality Assurance Specialist

Description:

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 conducts daily audits of medical claims to help ensure accurate benefit administration, provider network tiering, and 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.

Responsibilities

• Perform daily pre-pay and post-pay audits of medical claims.
• Review and audit medical claims to confirm 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 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.

Requirements:

• Associate degree or equivalent combination of education and experience.
• 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.
• Preferred experience with self-funded health plans and healthcare TPA environments.
• Preferred knowledge of Blue Cross Blue Shield processes and standards.
• Preferred experience with Javelina or similar claims administration systems.
• Preferred understanding of provider network tiering and implementation testing.

Benefits

After successfully completing a waiting period, eligible Full-time employees have access to our comprehensive benefits package, including:

• Fantastic medical, dental, and vision insurance*
• Twice annual employer HSA contributions, covering 50% of the HDHP plans 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** WOW! (100% fully vested after 3 years)
• 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

*60 day waiting period

**90 day waiting period

Who We Are

Cobalt Benefits Group has been named one of the Best Companies to Work for in NH 2026 by NH Business Magazine! As a trusted third-party administrator (TPA) specializing in self-funded benefit plans, Cobalt Benefits Group (CBG) is committed to helping employers find high-quality coverage at a cost they can afford. We administer self-funded insurance benefits through our four lines of business: EBPA, Blue Benefit Administrators of Massachusetts, CBA Blue, and Great Bay Administrators. With over 30 years of experience and a dedicated team of more than 300 employees, we work collaboratively to build customized self-funded health plans, manage claim payments and disputes, and administer other specialized programs such as FSAs, HSAs, COBRA, and retiree billing. Join us as we match employers across our region with the right solutions for their employee benefit needs. To learn more about working at CBG, visit

Cobalt Benefits Group is an Equal Employment Opportunity employer.

Cobalt Benefits Group participates in E-Verify to confirm the employment eligibility of all new hires.

Equal Opportunity Employer, including disability/protected veterans

Compensation details: 45000-51000 Yearly Salary

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