Provider Quality Analyst

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Navitus Health Solutions

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2003

💼 Consulting

🛡️ Insurance

🏥 Healthcare

Consulting • Insurance • Healthcare

Navitus Health Solutions is a pharmacy benefit manager (PBM) that provides transparent, people-centered pharmacy benefit solutions to health plans, employers, government programs and other plan sponsors. The company operates a 100% pass-through, cost-plus model that emphasizes lowering medication costs, managing formularies, specialty drug management (including a cost-plus specialty pharmacy), claims adjudication, pharmacy network management, and member enablement and support services. Navitus positions itself as a fiduciary partner focused on affordability, compliance, clinical quality and improving health outcomes through tailored PBM services and digital health integrations.

📋 Description

• Monitor, validate, and maintain provider and prescriber data for accuracy, completeness, and compliance • Intake, triage, prioritize, and resolve data quality issues based on risk, impact, and business needs • Investigate and resolve discrepancies or duplications affecting claims adjudication, system performance, and reporting integrity • Assist with Prescriber Edits on claims • Perform root cause analysis and recommend corrective actions • Validate and reconcile internal and external data sources, vendor data feeds, and enrichment files • Contact CMS and State Medicaid Programs to resolve prescriber data clarity issues • Resolve issues involving sanction monitoring, defects, exclusion conflicts, and provider restrictions • Escalate complex challenges, overrides, and data conflicts • Prepare documentation for audit readiness, regulatory inquiries, and client requests • Execute data governance controls, validation checks, and exception handling • Maintain SOPs, work instructions, and supporting documentation • Track, analyze, and communicate data quality trends, risks, and performance metrics • Contribute to process improvements, reporting, and automation efforts

🎯 Requirements

• Bachelor’s degree or equivalent work experience required • 2 years of experience working with provider data and/or validation through healthcare billing, accounts receivable, or credentialing required • Experience with data analysis required • Experience with healthcare claims processing required • Experience with issue resolution required • Experience with process improvement required • Participate in, adhere to, and support compliance program objectives • Ability to consistently interact cooperatively and respectfully with other employees • Must reside in an eligible US state because remote work is unavailable in Alaska, Delaware, Hawaii, Idaho, Iowa, Louisiana, Maine, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming

🏖️ Benefits

• Health insurance • Dental insurance • Vision insurance • 20 days paid time off • 4 weeks paid parental leave • 9 paid holidays • 401K company match of up to 5% with no vesting requirement • Adoption Assistance Program • Flexible Spending Account • Educational Assistance Plan • Professional Membership assistance • Referral Bonus Program – up to $750! • STAR Bonus % (At Risk Maximum) 5.00