Sr. Claims Integrity & Quality Analyst, Health Plan Operations

Job Summary

This key role is responsible for conducting in-depth analysis of high-dollar and complex claims, including IDR's, and Balance Billing scenarios, to ensure the supporting medical documentation validates the billing received for payment. This role is critical in driving solutions for first pass claims payment accuracy. Collaborate with payment integrity to ensure compliance with commercial health plan policies, contract agreements, and industry regulations.

Minimum Requirements

• BA/BS degree in a related field
• Minimum 5 years of experience in healthcare claims auditing, coding auditing, or formal quality assurance program experience
• Broad knowledge of provider billing guidelines, payer reimbursement policies, medical policy guidelines, and commercial insurance plans
• Requires at least one of the following current certifications from AAPC or AHIMA: RHIA, RHIT, CCS, CIC, or CPC
• Minimum 5 years of experience working with ICD-10CM, MS-DRG, AP-DRG, and APR-DRG coding standards
• Experience identifying root causes and driving corrective actions
• Strong analytical and investigative skills

Preferred Skills, Capabilities And Experience

• Health plan or payer-side experience
• Experience with claims configuration validation
• Experience supporting automation initiatives
• Experience working in a high-growth environment
• Clinical nursing with exposure to hospital bill auditing. Unrestricted Registered Nurse (RN) license
• Proficiency in Google Workspace and experience with audit tracking systems and data analytics tools (Snowflake, Streamlit, Claude)