Healthcare Claims Quality Analyst

Job Description

• Evry Health is seeking a Healthcare Claims Quality Analyst to support our claims operations team. The Quality Analyst will perform in-depth audits of medical claims processing to ensure payment accuracy, healthcare compliance, and adherence to plan benefits and industry regulations. This fully remote position will be responsible for conducting detailed quality audits on complex medical claims, disputes, payment adjustments, and medical claim adjudication decisions. Our priority is always to exceed member and provider expectations through excellent quality results. This role requires someone who is exceptionally detail-oriented, a strong communicator, both verbally and in writing, and a person who thrives when faced with challenges or problems to solve. Note: This is a healthcare claims auditing position focused on medical claim accuracy and compliance, not a software testing or IT quality assurance role. The Claims QA Analyst reports to the Vice President of Operations and should be comfortable partnering with senior leadership daily. While this is a remote role, you must reside in the United States and in the Eastern or Central time zone. About Evry Health and Globe Life We are on a mission to bring humanity to health insurance. Our high-technology health plans expand benefits, increase access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives. Evry Health is the major medical division of Globe Life (NYSE:GL). Globe Life has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, Globe Life has earned an A (Excellent) rating or higher from A.M. Best Company.
• Roles and Responsibilities In collaboration with the VP of Operations, develop/formalize the audit program, including the appropriate statistical sample size, quality results report, employee scorecard, error taxonomy, etc. Perform a wide range of quality responsibilities aimed at maintaining service excellence and driving continuous improvement in claim accuracy. Become a subject matter expert in medical claims adjudication and claims processing guidelines to evaluate Claims Analyst performance and payment accuracy. Propose documentation updates, workflow improvements, or changes to enhance the claims processing experience. Report on trends and training opportunities. Report out results to the employee and summarize weekly performance into monthly results. Follow up on errors to ensure claims are corrected prior to check run. Develop a rebuttal process to ensure errors are appropriately assigned. Create monthly KPI report that summarizes results, top error trends and recommendations for closing any gaps.
• Experience and Skills Desired You have a minimum of 3-5 years commercial health plan experience You have 2-3 years’ experience performing claims auditing or quality review functions. You have expertise in medical claims adjudication and healthcare claims processing You are familiar with healthcare compliance requirements and claim processing regulations You have a solid knowledge of medical and insurance industry terminology. You are an excellent communicator, both verbally and in writing and can articulate and communicate complex topics to a broad audience. You can perform comfortably in a fast-paced, deadline-oriented work environment. You possess strong attention to detail and problem-solving skills with a high level of accuracy. You are not afraid to express new ideas or suggestions for improving processes. You are skilled at identifying and implementing tools to improve the claims quality assurance process, including QA reporting and tracking mechanisms to allow easy identification of trends or quality issues. You collaborate with and support business and operational units across the organization. You are proficient in Microsoft Office applications Word, Excel, Outlook, OneNote, etc. You have prior experience using a CRM, preferably Salesforce.
• Telecommuting Requirements This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas. Company business hours are weekdays 9-5 CST. We will only consider candidates in the United States who reside in the CST or EST time zones. Required to have a dedicated work area established that is separate from other living areas and provides information privacy. Ability to keep all company sensitive documents secure. Must live in a location that receives an existing high-speed internet connection/service.
• Benefits Package Competitive salary Comprehensive health, dental, and vision insurance as well as life and disability Retirement savings plan with company match Generous time off/vacation Professional development opportunities Flexible and remote work environment
• Evry Health is an EEO employer - Read More Here
• We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
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