Claims Quality Business Analyst

We need to output HTML fragment with sections: h3 headings for sections present. Must not repeat job title. Must not include Job ID etc. Must remove boilerplate like EEO, legal, etc. Must preserve substantive info. We need to identify sections: Position Purpose (maybe as a paragraph). Responsibilities (multiple subparts). Education and Experience Required (maybe as Requirements). Preferred Experience (maybe as Qualifications or Skills). Benefits, Pay, Schedule not present, so omit those sections. We need to use

for section headings: e.g., About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. But we should only include sections that have real content. The posting includes "Position Purpose" (maybe About the role). It includes "Responsibilities" (multiple bullet-like paragraphs). It includes "Education and Experience Required" (maybe Requirements). It includes "Preferred Experience" (maybe Qualifications or Skills). There's no explicit Benefits, Pay, Schedule. We need to decide mapping: Use headings as per list: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We can map: - About the role: Position Purpose paragraph. - Responsibilities: the big Responsibilities section (including sub-bullets). - Requirements: Education and Experience Required. - Qualifications: Preferred Experience (maybe also Skills? but we have separate Skills heading; we could put preferred experience under Qualifications, and maybe skills under Skills? However the preferred experience includes many skill-like items: "Experience working with claims platforms...", "Knowledge of encounter data reporting...", "Lean Six Sigma...", "Advanced Excel...", etc. Those could go under Skills. But we have both Qualifications and Skills headings; we need to decide. The instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can have multiple sections. We need to include a section only when posting has real, specific content for it. So we need to see if there is content for Qualifications and Skills separately. The posting lumps "Preferred Experience" and then lists many items that are both experience and skills. Could split: Qualifications: Preferred Experience (maybe bullet list). Skills: Advanced Excel and data analysis skills, Ability to analyze large data sets, Strong verbal and written communication skills, etc. But the posting also includes "Strong analytical and reporting skills." under Required. That could be Skills. However we need to avoid inventing sections; we can put all preferred items under Qualifications, and maybe not have a separate Skills section if we don't have distinct skills content beyond what's already in Qualifications. But we have a Skills heading in the list; we could still include it if we have content. The posting does mention "Strong analytical and reporting skills." under Required, and later "Advanced Excel and data analysis skills.", "Ability to analyze large data sets and identify operational trends.", "Strong verbal and written communication skills." Those are skills. So we could create a Skills section with those items. Thus we can have: - About the role (Position Purpose) - Responsibilities - Requirements (Education and Experience Required) - Qualifications (Preferred Experience) - Skills (the skill-based items from Preferred and maybe from Required) We should not include Benefits, Pay, Schedule. We must not repeat job title. Must not include metadata like Job ID. Must remove boilerplate: EEO statement, legal disclaimer, "Note: This description indicates..." etc. Also remove "No Third Party Agencies or Submissions Will Be Accepted." etc. Also remove "Powered by JazzHR". Also remove "DFWP Opportunities posted here..." etc. Also remove "Our company is committed to creating a diverse environment..." etc. Also remove "Any and all information may change without notice." etc. We must preserve all substantive information: that includes the Position Purpose paragraph, the responsibilities bullet points (though they are in prose with line breaks). We need to convert to

• for any list of duties/requirements/benefits. The responsibilities section includes multiple sentences; we can treat each sentence or clause as a list item? The instruction: Use
  • for any list of duties/requirements/benefits. So we need to turn the responsibilities into a list. The responsibilities section includes multiple bullet-like items separated by periods and line breaks. We'll parse them into logical items. Let's extract responsibilities text: "Claims Quality Oversight Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements. 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 communicate 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." We need to turn each of these into list items. Could group under subheadings? But we only have

    for section headings, not subheadings. We could keep the bold headings as plain text inside

    or maybe as . But we must not invent new headings. We can keep them as part of list items. Simplify: create a

    with each line as
    • . Keep the content exactly. Similarly for Requirements: "Education and Experience Required 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." We'll make a
      list. Qualifications: "Preferred Experience 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." We'll make a
      . Skills: from Preferred and Required: "Advanced Excel and data analysis skills. Ability to analyze large data sets and identify operational trends. Strong verbal and written communication skills." Also maybe "Strong analytical and reporting skills." but that's already in Requirements; we could still include but might duplicate. Better to keep Skills distinct: include those three items. We must not include boilerplate like "Note: This description indicates..." etc. Now produce HTML fragment:

      About the role

      Position Purpose: The Claims Quality Business Analyst is responsible for analyzing 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.
      • 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 communicate 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.
      But note: Some items like "Claims Quality Oversight" are headings; they'd be list items but maybe better to keep as inside
      • . However instruction: Use
        • for any list of duties/requirements/benefits. It didn't forbid other markup inside. We could keep them as plain text; it's okay. Similarly for 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:

          Qualifications

          • 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.
          Skills:

          Skills

          • Advanced Excel and data analysis skills.
          • Ability to analyze large data sets and identify operational trends.