Responsibilities
- Lead policy and quality improvement initiatives that enhance medical claim accuracy and reduce overpayments across pre- and post-pay programs.
- Partner with internal teams and external vendors to identify overpayment opportunities and design effective edit rules with balanced accuracy and financial outcomes.
- Own assigned edits throughout their lifecycle, monitoring performance, implementing corrective actions, and driving continuous improvement.
- Analyze weekly and monthly performance reports to assess effectiveness, identify trends, and recommend enhancements.
- Build clear, data-driven business cases that include root cause analysis, financial and operational impact, resource needs, and short- and long-term solutions.
- Investigate performance variances, including data quality issues, and address root causes in collaboration with technical partners.
- Monitor quality metrics, false positives, and adjustment trends to improve overall program performance.
- Collaborate closely with quality, business intelligence, and technology teams to implement new edits, enhance reporting, and resolve issues.
- Conduct data queries and mining to support pre-pay correction efforts and document work accurately in intake and tracking tools.
- Contribute to projects and data-related initiatives that advance enterprise affordability and accuracy goals.
Requirements
- High School Diploma or G.E.D.
- 5+ years of experience in medical claims processing, program management, or a related analytical role.
- Strong knowledge of medical claim systems and workflows, with hands-on experience in at least one major claims platform.
- Demonstrated analytical, problem-solving, and data interpretation skills.
- Ability to work independently while collaborating effectively with cross-functional teams.
- Clear and confident written, verbal, and presentation communication skills.
- Proficiency with Microsoft Office tools and data analysis techniques.
Nice to Have
- Bachelor’s degree in a related field.
- Experience with audit findings, claim quality analysis, or payment integrity programs.
- Familiarity with data mining, predictive modeling, or business intelligence tools supporting claims accuracy.
Benefits
- medical
- vision
- dental
- well-being and behavioral health programs
- 401(k)
- company paid life insurance
- tuition reimbursement
- a minimum of 18 days of paid time off per year
- paid holidays
Additional Information
- The internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
