Healthcare Claims Quality Analyst

The Claims Quality Assurance Analyst is responsible for monitoring and documenting production quality in support of departmental goals and initiatives, with a primary focus on claims auditing and claims-related interactions within the Revenue Cycle Management (RCM) function. The Claims Quality Assurance Analyst reviews claim audit results and claim transactions, as well as evaluates both verbal and written contacts, to ensure accuracy, completeness, proper documentation, and compliance with policies, procedures, and applicable regulations.

The Analyst supports the design and maintenance of quality monitoring formats and standards, documents quality findings, and effectively presents results, feedback, and trend data to leadership to drive continuous improvement. The ideal candidate has prior healthcare claims auditing experience, working knowledge of claims billing practices and state billing requirements. DME claims experience is preferred.

While this role is primarily focused on claims audit activities, the Analyst may also support quality monitoring and audit needs across other operational areas based on business priorities.

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES 

The Claims Quality Assurance Analyst responsibilities include but are not limited to:

• Primarily monitor Claims quality and audit functions, with support for other operational departments as business needs require; DME claims experience preferred
• Participate in and support the design of quality monitoring forms and quality standards
• Record evaluations utilizing departmental quality monitoring forms
• Conduct claims audit reviews to confirm claim accuracy, required documentation, workflow adherence, and compliance with internal policies and applicable requirements
• Evaluate claim handling for appropriate billing practices, including awareness of state-specific billing requirements as applicable to the claim type and line of business
• Support Revenue Cycle Management (RCM) quality outcomes by identifying audit findings that drive denials, rework, or reimbursement issues and partnering with operations to reduce defects
• Identify and trend audit findings (e.g., documentation deficiencies, timeliness, process gaps, billing errors) and communicate actionable insights to leadership and operations partners
• Collect, evaluate, report on and track operations data against performance metrics
• Prepare and analyze quality reports for Management review
• Prepare and facilitate quality calibration sessions with designated department leads · Facilitate meetings and prepare presentations related to insight analysis
• Collaborate with the leadership team to create content-based training that will equip operations personnel with the necessary skills for success
• Monitor trends and provide input or feedback on the information reported on
• Identify, analyze and share ways to optimize the quality monitoring process
• Complete all evaluations, reports and employee coaching sessions on a timely basis
• Ability to learn new systems, tools, and methodologies as needed and continue progressing in a dynamic environment
• Support ad hoc quality monitoring, reporting and analysis activities based on operational needs
• Work and communicate cross-departmentally

QUALIFICATIONS:

• Minimum of 1 year of claims auditing experience supporting commercial, Medicaid, and Medicare lines of business, including working knowledge of billing rules and state/payer-specific requirements; DME preferred. Other QA/production experience a plus (or equivalent education and experience).
• Working knowledge of Revenue Cycle Management (RCM) workflows and downstream impacts (e.g., clean claim submission, edits, denials, appeals, payment posting/reconciliation) across commercial, Medicaid, and Medicare. · Desire and capability to emerge as a leader within the Operations team
• Consistent track record of 95% + in Quality and Production scores in current/previous roles
• Proficient understanding of QA methodologies and quality monitoring practices
• Demonstrated ability to rapidly gain product, process and tools knowledge and effectively communicate it to employees
• Ability to analyze data to identify root causes of quality issues and propose actionable solutions
• Excellent communication skills including listening, interpersonal, verbal, written, spelling and grammar
• Ability to coach/motivate employees with tact in order to facilitate optimal performance
• Must exhibit leadership capabilities and interpersonal skills
• Maintain confidential information and abide by necessary rules and regulations
• Strong organizational, problem-solving, and analytical skills
• Manage conflicting priorities while clearly communicating and managing expectations
• Proficiency in Word, Excel and PowerPoint for presentations and reports
• Flexible and able to multitask and work with changing priorities with enthusiasm
• Self-motivated, detail-oriented and prepared to work independently or as an active team player
• Ability to remain focused and motivated during the auditing process
• Healthcare experience preferred
• Fluent in Spanish and English preferred

What will you learn in the first 6 months?

• You will learn the function of the Quality Assurance team within the Operations organization.
• You will fully understand your job role and responsibilities and which tools assist you in your position
• Familiarized with Integra’s QA platform (Genie) and how to navigate through it. Including how to adjudicate an audit appeal
• Subject matter expert in the Policy and Procedures for the department(s) you audit
• During this time, you will set measurable goals for personal development and growth.

What will you achieve in 12 months?

1. You will be fully integrated with your job, company and team.
2. You will be contributing your skills and knowledge to meeting your department's goals.
3. You will become confident in leading meetings with Interdepartmental Management teams and presenting complex concepts related to quality analysis

EDUCATION:

• Bachelor’s Degree preferred or equivalent experience

Salary: $24.00/Hourly

 

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.