Senior Claims Integrity & Quality Analyst, Health Plan Operations

🔥 3 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $90k - $120k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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Curative

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2020

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

Curative is an employer-focused health insurance company offering a next-generation group health plan that emphasizes affordability, engagement, and simplicity. Their plans promise $0 in-network copays, $0 deductibles, and a single competitive monthly premium, along with a broad provider network, telehealth, an extensive $0-preferred prescription formulary, care navigators, and the Curative Cash Card to eliminate out-of-pocket costs in many settings. Curative markets to employers and brokers while providing members with resources like a Baseline Visit, care programs, online portals, and pharmacy services, and holds an A- rating from AM Best and HITRUST r2 certification.

📋 Description

• Conduct in-depth audits and clinical reviews of professional, institutional, ancillary, and high-dollar claims, focusing on adjudication accuracy, benefit application, pricing, and coding (ICD-10, CPT/HCPCS, DRG). • Utilize advanced coding expertise and workflow systems to substantiate audit findings, generate recoverable claims, and investigate potential fraud and utilization patterns. • Drive operational excellence by validating claims configuration, reimbursement methodologies, and processing logic. • Support the implementation of automated controls, advanced editing/AI solutions, and workflow enhancements to improve payment accuracy, reduce administrative costs, and contribute to the development of audit tools, policies, and procedures. • Identify trends, defects, and operational risks impacting claims quality. Develop reports and present findings and recommendations to operational leadership to drive corrective actions and improvement opportunities.

🎯 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.

🏖️ Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.) • $0 copays and $0 deductibles (with completion of our Baseline Visit) • Preventive and primary care built in • Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged) • One-on-one care navigation • Chronic condition programs (diabetes, weight, hypertension) • Maternity and family planning support • 24/7/365 Curative Telehealth • Pharmacy benefits • Comprehensive dental and vision coverage • Employer-provided life and disability coverage with additional supplemental options • Flexible spending accounts • Flexible work options: remote and in-person opportunities • Generous PTO policy plus 11 paid annual company holidays • 401K for full-time employees • Generous Up to 8–12 weeks paid parental leave, based on role eligibility.