About The Role
We are looking for a Senior Quality Analyst to join the team who will be responsible for verifying provider/hospital contracts and benefit verification to ensure processing outcomes are in line to established rules. This individual will support quality reviews and testing of all configuration setups prior to client implementation and go-live..
Primary Responsibilities
- Audit configuration against contract requirements to verify configuration following source documentation.
- Research claims issues to determine configuration gaps.
- Review and verifying fee schedules and provider contracted rates are configured correctly in line to provider contracts.
- Review and verify hospital contract configuration is consistent with hospital contracts.
- Review and verifying plan setup and benefit configuration is consistent with client approved benefit grids.
- Develop, prepare, and report on assigned projects outcome in a timely and efficient manner.
- Perform focus audits on claims projects.
- Recommend opportunities for sweep audit reports.
- Serve as a lead for team regarding any benefit and configuration issues or questions
Essential Qualifications
- 5+ years of provider and hospital claims experience
- understanding of Hospital contracts terminologies and various pricing mechanisms.
- understanding of, plan setup, benefits configuration and accumulators.
- Experience with building and running SQL queries.
- Working knowledge of medical terminologies and coding considered to be added advantage.
- MS Office Suite applications, including but not limited to: Word, Excel, Outlook, PowerPoint
- Strong analytical aptitudes, communication, and comprehension capabilities.
- Claim auditing experience is added advantage
- Strong Communication Skills
- High School or Diploma
At Brighton Health Plan Solutions (BHPS), we’re creating something new and different in health care, and we’d love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery systems. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers – and that’s why we’re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we’re fiercely committed to positively impacting our partners.
Company Mission:
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.
Company Vision:
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
*We are an EEO Employer
Top Skills
What We Do
Brighton Health Plan Solutions (BHPS) is a health care enablement company that is transforming the way health care is accessed and delivered. Our innovative, customizable, sustainable solutions encourage patient activation and improve the quality of care — all at lower cost. We effect impactful change for self-funded plan sponsors, health systems, and TPAs through our extensive health care expertise:
•Decades of health plan design and health plan management experience
•Proprietary MagnaCare, Create®, and Casualty provider networks
•Strong provider relationships
•Cutting-edge, white-labeled technology platform that enhances the
experience for providers, plan purchasers and health care consumers
