Senior Claims Integrity & Quality Analyst, Health Plan Operations

🕒 il y a 10 jours

🤠 Texas – Distant

🤠 Texas – Remote

💵 $90 000 - $120 000 / an

⏰ Temps Plein

🟠 Senior

⚙️ Opérations

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Curative

Site WebLinkedInTous les Emplois

501 - 1000 employés

Fondée en 2020

🏥 Santé

🛡️ Assurance

Healthcare • Insurance

Curative est une entreprise d'assurance santé orientée vers les employeurs, proposant un plan de santé de groupe de nouvelle génération mettant l'accent sur l'accessibilité financière, l'engagement et la simplicité. Leurs plans promettent zéro frais de consultation en réseau, zéro franchise et une prime mensuelle unique et compétitive, accompagnés d'un large réseau de prestataires, de télémédecine, d'une vaste liste de médicaments préférentiels à zéro, de navigateurs de soins et de la Curative Cash Card pour éliminer les coûts à la charge des membres dans de nombreux contextes. Curative s'adresse aux employeurs et courtiers tout en fournissant aux membres des ressources telles qu'une visite de base, des programmes de soins, des portails en ligne et des services de pharmacie. L'entreprise détient une note A- de AM Best et la certification HITRUST r2.

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.

🎯 Exigences

• 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.

🏖️ Avantages

• 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.