Claims Quality Business Analyst

About the Role

The Claims Quality Business Analyst analyzes claims operations, payment accuracy, compliance requirements, and quality performance metrics to identify opportunities for operational improvement, regulatory compliance, and member/provider satisfaction. This position serves as a liaison between Claims, Compliance, Quality, Provider Relations, IT, and Delegation Oversight to support accurate claims adjudication, encounter data integrity, and continuous process improvement.

Responsibilities

• Claims Quality Oversight
  • Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements for:
    • Remittance Advice (RA)
    • Denial Letters/IDN
    • Explanation of Benefits (EOB)
  • Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes.
  • Identify trends related to pended, denied, adjusted, and overturned claims.
  • Develop and maintain claims quality monitoring reports and dashboards.
  • Ensure claims communications accurately convey payment decisions, denial rationale, member responsibility, provider responsibility, and applicable benefit or payment explanations.
• Business Analysis
  • Gather business requirements for system enhancements and claims operational improvements.
  • Analyze claims workflows and recommend process improvements to increase efficiency and reduce rework.
  • Collaborate with IT, Delegates, and providers/vendors on claims system configuration, testing, and implementation activities.
  • Perform data validation and user acceptance testing (UAT) for claims-related system changes.
• Regulatory and Compliance Support
  • Evaluate claims operations for compliance with CMS Medicare Advantage requirements, AHCA requirements, and internal policies.
  • Lead implementation of regulatory, benefit, and operational changes affecting RA/EOB content, claims reason codes, remark codes, notices, and member/provider-facing explanations.
  • Assist with audit readiness activities, CAP development, and monitoring of corrective actions.
• Reporting and Analytics
  • Develop reports tracking:
    • Metrics/Claims turnaround time (TAT)
    • Auto-adjudication rates
    • Financial accuracy
    • Denial trends
    • Encounter submission quality/reporting
    • Claims Adjudicator Production
  • Present findings and recommendations to leadership.
• Cross-Functional Collaboration
  • Partner with IT, Quality, Compliance, Medical Management, Provider Relations, and Member Services teams.
  • Participate in operational committees and quality improvement initiatives.
  • Assist with provider and internal staff education related to claims processes and regulatory requirements.

Requirements

• Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field.
• 3–5 years of health plan claims operations, business analysis, or healthcare analytics experience.
• Experience with Medicare Advantage, Medicaid, or managed care claims processing.
• Strong analytical and reporting skills.

Qualifications (Preferred)

• Experience working with claims platforms (Facets, QNXT, HealthRules, or similar).
• Experience supporting CMS audits and regulatory compliance activities.
• Knowledge of encounter data reporting and MA organization requirements.
• Lean Six Sigma or process improvement experience.
• Knowledge of Medicare Advantage claims payment methodologies.
• Understanding of claims adjudication and provider reimbursement concepts.
• Advanced Excel and data analysis skills.
• Ability to analyze large data sets and identify operational trends.
• Strong verbal and written communication skills.