Claims Quality Assurance Analyst

Network Health's success is deeply rooted in its mission to build healthy and strong Wisconsin communities. This mission shapes every decision we make, including the selection of individuals who join our growing team.

The Claims Quality Assurance Analyst plays a critical role in ensuring operational excellence. This position conducts detailed inspections of operational data to identify inefficiencies, ensure adherence to quality standards, and support the development of best-in-class processes and services.

In addition, the role includes performing internal audit functions to assist the Internal Audit team in meeting Model Audit Requirements (MAR) or fulfilling Service Level Agreements. The Claims Quality Assurance Analyst collaborates with subject matter experts across various departments and references resources such as reimbursement policies, Desk Level Procedures (DLPs), Certificates of Coverage (COC), Explanations of Coverage (EOC), CMS regulations, and provider contracts to resolve claim payment accuracy issues effectively.

Location : Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model.

Hours : 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2024 Annual Report video to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities

• Demonstrate commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health
• Appropriately apply all organizational and regulatory principles, procedures, requirements, regulations, and policies
• Performs data entry, claim, and enrollment monitoring activities and scores performance according to set criteria and timelines.
• Compiles results into meaningful, actionable reports with recommendations for process improvements
• Documents findings and makes recommendations for efficiencies based on monitoring results.
• Responsible for accurate and timely performance of monitoring activities
• Maintains and updates tracking databases and / or files to support monitoring activities.
• Review and audit health care claims to ensure payment accuracy.
• Provide and discuss audit results with Claims Leadership and Claims team members.
• Runs claims reports necessary to conduct audits, requests custom claim reports as needed.
• Support audits in relation to monthly Service Level Agreements
• Assist Internal Audit with meeting certain MAR functions.
• Provide feedback to desk level procedure (DLP) documents to endure documents are current.
• Actively participates in shared accountability and commitment for departmental and organization-wide results. Supports departmental / team goals and objective.
• Other duties as assigned.

Job Requirements :

Network Health is an Equal Opportunity Employer

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.