Quality Assurance Examiner

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Health Plans, Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1981

⚕️ Healthcare Insurance

💳 Fintech

🤝 B2B

Healthcare Insurance • Fintech • B2B

Health Plans, Inc. (HPI) is a leading national third-party administrator (TPA) that specializes in self-funding solutions for employers and benefits brokers. HPI offers innovative health plan designs, including Consumer-Driven Health Plans (CDHP) and reference-based pricing, tailored to meet the unique needs of individual markets. With a commitment to providing advanced analytics and customized solutions, HPI aims to put employers in control of their healthcare costs while enhancing the member experience.

📋 Description

• Conduct internal audits of high-dollar claims and adjustment transactions, including audits exceeding $50,000 to $100,000+. • Partner with external audit vendors to address questions, provide feedback, and ensure audit accuracy. • Process claim adjustments, refunds, recoveries, voids, reissues, and Medicare demand transactions. • Analyze adjustment and refund activity to identify trends, determine root causes, and recommend process, training, or system improvements. • Investigate potential operational or payment issues and provide recommendations to management. • Collaborate with provider billing vendors to request refunds, process claim adjustments, and review audit-related correspondence. • Monitor and track adjustment activity, maintaining accurate documentation and reporting. • Prepare and present monthly department audit results and key findings. • Support continuous improvement initiatives by identifying opportunities to enhance accuracy, efficiency, and compliance within claims and audit processes.

🎯 Requirements

• Bachelor’s degree or an equivalent combination of education and work experience. • Three to five years of claims processing experience required. • Prior experience in the healthcare or health insurance industry required. • Strong analytical and problem-solving skills with exceptional attention to detail. • Ability to manage multiple priorities in a fast-paced environment while maintaining a high degree of accuracy. • Excellent organizational and time management skills with the ability to meet deadlines. • Effective verbal and written communication skills, with the ability to interact professionally across all levels of the organization. • Ability to work independently while also contributing collaboratively as part of a team. • Demonstrated ability to understand system interactions and identify the downstream impact of process changes. • Proven ability to follow through on assignments, proactively address issues, and ensure timely resolution. • Sound judgment and discretion in handling confidential and sensitive information. • Commitment to continuous improvement and identifying opportunities to enhance quality, accuracy, and operational efficiency.

🏖️ Benefits

• Medical, Dental and Vision and Prescription Drug Coverage • Fitness Reimbursement Benefit • Employee Assistance Program • Flexible Spending Account & Health Savings Account • 401(k) and Quarterly Bonuses • Generous Paid-Time Off & Volunteering Opportunities • Educational Assistance & Professional Development Opportunities