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At Collective Health, our Quality Team is the engine driving continuous improvement, ensuring our quality framework not only meets but also propels our strategic business goals forward. As a Senior Quality Specialist, you'll be indispensable.

You'll pinpoint processing errors, dissect trends, and partner with consultants to launch improvement programs that deliver measurable impact. We're seeking a professional who is exceptionally detail-oriented and genuinely passionate about elevating accuracy, productivity, and overall process efficiency.

What you'll do:

• Lead comprehensive quality reviews of Member Claims Advocates' work, specifically targeting complex cases, high-dollar claims, and new hire performance to rigorously assess accuracy and decision-making.
• Manage and support responses to external audit requests, ensuring data integrity and compliance.
• Actively participate in Quality team meetings and calibration sessions, championing consistent scoring methodologies and a deep understanding of key metrics.
• Consistently maintain and strive to exceed an acceptable Claim Review Accuracy level.
• Contribute significantly to data-driven trend analysis, identifying root causes and actionable insights.
• Execute ad hoc claim reviews and perform in-depth deep-dive analyses to uncover systemic issues.
• Collaborate closely with Team Leads to develop and support training initiatives.
• Ensure strict adherence to all documented QA workflows and best practices.

To be successful in this role, you'll need:

• 3+ years of experience as a medical claims examiner AND 2+ years dedicated to auditing and providing quality assurance feedback on medical insurance claims. Your combined background must demonstrate expertise in accurate benefit determination and a meticulous approach to ensuring claims accuracy and compliance.
• Advanced command of health insurance operations, including intricate details of deductibles, copayments, coinsurance, out-of-pocket maximums, in-network vs. out-of-network benefits, and various plan types (e.g., PPO, EPO, HDHP).
• Robust knowledge of medical coding systems (ICD-10, CPT, HCPCS, institutional revenue codes).
• Comprehensive understanding of regulatory guidelines and restrictions (HIPAA, ERISA, federal, state, and local mandates), coupled with the agility to adapt to evolving changes.
• Solid grasp of complex medical terms, conditions, procedures, and basic human anatomy/physiology.
• Exceptional attention to detail paired with a strong analytical mindset.
• Proficiency in reading and interpreting EDI formats (837i and 837p).
• Superior written and verbal communication skills to effectively collaborate, provide constructive feedback, offer clear guidance, and deliver precise instructions.
• Demonstrated knowledge and experience in software systems such as Microsoft or Google
• High degree of self-motivation, intellectual curiosity, and a strong sense of ownership.
• Exceptional research capabilities.
• Strong interpersonal relationship-building skills.
• Excellent organizational and time management skills.
• Effective listening skills and the ability to maintain focus amidst distractions.
• Absolute discretion when handling sensitive or private information.
• Preferred previous experience working for a Third Party Administrator that utilizes multiple repricing networks.

Pay Transparency Statement

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office three days per week (Plano, TX) or two days per week (Lehi, UT).#LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the hourly rate, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.