drjobs Senior Quality Specialist, Member Claims

Senior Quality Specialist, Member Claims

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1 Vacancy
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Job Location drjobs

Plano, TX - USA

Monthly Salary drjobs

Not Disclosed

drjobs

Salary Not Disclosed

Vacancy

1 Vacancy

Job Description

At Collective Health were transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology compassionate service and world-class user experience design.

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 youll be indispensable.

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

What youll 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 youll 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 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 UT Pay Range

$27.20$34 USD
Plano TX Pay Range
$29.85$37.40 USD

Why Join Us

  • Mission-driven culture that values innovation collaboration and a commitment to excellence in healthcare
  • Impactful projects that shape the future of our organization
  • Opportunities for professional development through internal mobility opportunities mentorship programs and courses tailored to your interests
  • Flexible work arrangements and a supportive work-life balance

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race religion color national origin gender sexual orientation age marital status veteran status or disability status. Collective Health is committed to providing support to candidates who require reasonable accommodation during the interview process. If you need assistance please contact .

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Senior IC

Employment Type

Full Time

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