Medical Claims Quality Assurance Analyst

Description

Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Medical Claims Quality Assurance Analyst, you’ll play an important role in helping us offer customized, self-funded insurance options to our clients and members.

The Medical Claims Quality Assurance Analyst plays a critical role in ensuring the accuracy and compliance of claims processing in alignment with plan-specific and company guidelines. This position involves enforcing quality procedures, monitoring performance, identifying and addressing quality issues, and conducting both internal and external audits. The ideal candidate is a skilled communicator who excels in verbal, written, and electronic correspondence and thrives in a dynamic, team-oriented environment. The role also demands high levels of accuracy, problem-solving, and flexibility to adapt to changing priorities.

Responsibilities:

• Quality Standards and Auditing: Perform audits on production, company guidelines, and system configurations to maintain quality standards. Conduct internal Prepay and Post-pay audits to identify discrepancies and ensure compliance. Execute LDLA (Licensee Desk-Level Audit) processes. Perform MTM (Member Touchpoint Measures) audits and prepare monthly reports.
• Collaboration and External Engagement: Work closely with external auditors to support their review processes and ensure audit readiness. Respond promptly and professionally to email correspondence from internal and external stakeholders.
• Process Improvement and Problem-Solving: Identify and address quality issues, proposing solutions to enhance claims processing workflows. Actively participate in the development and enforcement of quality assurance procedures and guidelines.

Requirements

Education and Experience:

• Associate’s degree or 2+ years of relevant experience in quality assurance, auditing, or claims processing.
• Minimum 2 years of internal claims processing experience, preferably in a healthcare benefit or TPA environment.

Skills and Competencies:

• Strong working knowledge of Microsoft Office Suite (Outlook, Word, Excel).
• Proven expertise in claims processing and an in-depth understanding of related systems and workflows.
• Demonstrated customer service skills with the ability to manage both internal and external relationships effectively.
• Exceptional problem-solving and analytical skills to evaluate data and identify patterns.
• Ability to work independently, prioritize tasks, and meet deadlines in a high-pressure environment.
• Strong organizational skills with the capacity to plan and manage multiple assignments concurrently.

Preferred Qualifications:

• Familiarity with auditing tools or software.
• Knowledge of healthcare regulations and compliance requirements, including HIPAA.
• Experience with TPA operations and plan administration processes.

Benefits:

After successfully completing a waiting period, eligible Full-time employees have access to our comprehensive benefits package, including:

• Fantastic medical, dental, and vision insurance*
• Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible!
• Company provided Basic Life and AD&D
• Company paid Short-Term and Long-Term Disability**
• Flexible Spending Accounts*
• 401(k) Retirement Plan with up to a 6% employer-match** WOW! (100% fully vested after 3 years)
• 10+ paid holidays
• Generous paid vacation and sick time
• Annual Volunteer Paid Day
• Annual Tuition Reimbursement
• Annual Health and Wellness Reimbursement
• Lots of fun company events

Who We are:

As a trusted third-party administrator (TPA) specializing in self-funded benefit plans, Cobalt Benefits Group (CBG) is committed to helping employers find high-quality coverage at a cost they can afford. We administer self-funded insurance benefits through our three companies: EBPA, Blue Benefit Administrators of Massachusetts, and CBA Blue.

With over 30 years of experience and a dedicated team of more than 200 employees, we work collaboratively to build customized self-funded health plans, manage claim payments and disputes, and administer other specialized programs such as FSAs, HSAs, COBRA, and retiree billing. Join us as we match employers across our region with the right solutions for their employee benefit needs. To learn more about working at CBG, visit https://www.cobaltbenefitsgroup.com/careers/.

Benefit Waiting Period Notes:

*60 day waiting period

**90 day waiting period