Healthcare Claims Quality Assurance Specialist

Job not on LinkedIn

🕒 September 18

🗻 New Hampshire – Remote

🗻 New Hampshire – Remote

💵 $45k - $51k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

👻 Ghost score 18%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA)

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

⚖️ Legal

🛡️ Insurance

Consulting • Legal • Insurance

Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA) is a full service Third Party Administrator (TPA) that specializes in the customization, marketing, and operation of self-funded employee benefit plans. With over 30 years of experience and a team of over 195 employees, CBG provides a wide array of products and services including self-funded medical and dental plans, Flexible Spending Accounts, Health Reimbursement Arrangements, and COBRA management. CBG aims to assist employers in building custom benefit plans while managing costs and ensuring compliance with regulations.

📋 Description

• Perform daily pre-pay and post-pay audits of medical claims • Review and audit medical claims to confirm accurate processing in accordance with member benefits, provider contracts, fee schedules, and plan requirements • Validate benefit application, including deductibles, copays, coinsurance, eligibility, and plan provisions • Audit provider network tiering and reimbursement accuracy • Verify claims are processed according to provider contracts, fee schedules, and client plan designs • Identify, document, and communicate claim processing errors and trends • Conduct production, system configuration, and operational quality audits • Complete LDLA (Licensee Desk Level Audit) and MTM (Member Touchpoint Measurement) reviews • Support external client, regulatory, and internal audit activities • Participate in new client, renewal, and plan change testing efforts • Produce audit reports and recommend corrective actions and process improvements • Collaborate with Claims, Provider Maintenance, Customer Service, Configuration, and Implementation teams to resolve quality issues

🎯 Requirements

• Associate degree or equivalent combination of education and experience • 3+ years of hands-on health insurance claims processing or adjudication experience, including reviewing medical claims for accuracy and applying benefit provisions • Strong understanding of medical claims adjudication and benefit administration • Experience reviewing provider contracts, pricing methodologies, and network structures • Advanced analytical, organizational, and problem-solving skills • Proficiency with Microsoft Office, including Excel, Word, Outlook, and Teams • Excellent written and verbal communication skills • Ability to work independently while managing multiple priorities • Preferred experience with self-funded health plans and healthcare TPA environments • Preferred knowledge of Blue Cross Blue Shield processes and standards • Preferred experience with Javelina or similar claims administration systems • Preferred understanding of provider network tiering and implementation testing • Ability to work in the United States as a new hire, as employment eligibility is verified through E-Verify

🏖️ Benefits

• 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 • 100% fully vested after 3 years • 10+ paid holidays • Fully Paid half day Summer Fridays • Generous paid vacation and sick time • Annual Paid Volunteer Day • Annual Tuition Reimbursement • Annual Health and Wellness Reimbursement • Fun company events

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