Position Title: Senior Quality Assurance Analyst
Department: Operations / Payment Integrity
Job Grade: Senior Professional (16)
Location: Remote
Reports to: Director of Quality Assurance
Job Summary
As a Senior Quality Assurance Analyst at SmartLight Analytics, you will play a critical role in ensuring the accuracy, consistency, and quality of work produced by our Clinical Analysts. While our Clinical Analysts identify, investigate, and report on payment integrity issues in healthcare claims, your responsibility is to review their work for completeness, accuracy, and adherence to high quality standards.
This position requires strong knowledge of medical coding and payment integrity. You will act as the final checkpoint before findings are released to clients and carriers, ensuring that every deliverable is defensible, well-documented, and aligned with SmartLight’s high standards.
The preferred candidate would be local to the Dallas, Texas area; however, this position is a hybrid position, and a qualified candidate can work remotely with periodic travel to the office.
This position is only eligible for legal residents of the United States of America.
This is NOT a Data Analyst/Engineer Position with SQL and data sets. If you have this skill set, do not apply. This analyst role is analyzing medical claims and diagnostic codes ,and not working with large data sets.
Key Responsibilities
Quality Assurance:
Perform quality reviews of Quality Analyst work products
Review claims data
Confirm proper referral case presentation including referral reason, logic for the reason and proposed corrective action
Compare with client SPD and industry best practices
Validate identified savings values
Provide feedback to analysts on errors, omissions, or opportunities for improvement.
Contribute to QA standards documentation for a clearer definition of Quality
Analyze trends in quality issues and implement root cause / corrective actions
Serve as a resource for Quality Analysts by clarifying QA standards
Support the creation of a “culture of quality” among the clinical operations team
Collaboration and Stakeholder Engagement:
Work closely with healthcare professional consultants, clinical teams and business analysts to understand the data needs of stake holders
Collaborate with data scientists and engineers to build and refine analytics tools that enable improved decision-making
Present findings and insights to internal teams, clients, and stakeholders in a clear, understandable manner
Quality Control and Data Integrity:
Ensure the quality, accuracy, and integrity of clinical data by conducting data validation, cleaning, and preparation.
Identify and resolve issues related to data discrepancies, missing data, or inconsistencies within clinical datasets
Required Qualifications
3- 5 years’ work experience related to healthcare billing, claims adjudication, fraud investigation, payment integrity operations and/or healthcare reimbursement
Strong critical thinking and writing skills
Experience with manipulating, analyzing, and interpreting large datasets
Strong knowledge of clinical terminology, medical procedures, and healthcare workflows
Ability to be concise, independent and provide defensible decisions in writing
Must have solid ability to accurately document findings in written form
Detail-oriented with excellent communication skills (oral presentations and written) and interpersonal skills
Strong PC knowledge and skills, including all Microsoft Office products
3-5 years’ experience with CPT and HCPCS code terminology
Preferred Qualifications
Certified Coding Specialist (AAPC or AHIMA) preferred
Bachelors degree in nursing or related field preferred
3+ years of experience working in the group health business or experience in a health care provider’s practice
Experience in claims adjudication and the healthcare payment process
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (commercial health plans and/or dental plans)
Experience with data analysis as it relates to healthcare claims adjudication
Skills and Competencies
Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomes
Problem- Solving: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutions
Attention to Detail: High level of precision and accuracy in handling critical data
Communication Skills: Excellent written and verbal communication, with the ability to present technical information to non-technical audiences
Collaboration: Team-oriented with a focus on collaboration across multidisciplinary teams
Who is SmartLight Analytics
SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes
Top Skills
What We Do
SmartLight Analytics was formed by a group of industry insiders driven to make a meaningful impact on the rising cost of employee healthcare. Using our statistical, clinical, fraud detection, coding and claims expertise we deliver the most complete wasteful spend reduction solution directly to self-funded employers.
SmartLight utilizes proprietary inferential analytics customized to your employee population, followed by expert clinical review on 100% of your medical claims. Our team partners with your TPA to implement solutions resulting in a lower per employee healthcare spend. We let your data tell us where to look without any preconceived notions about what the errors are beforehand.
Our approach is low-touch and involves zero employee involvement. SmartLight consistently delivers a higher ROI compared to other cost reduction solutions on the market.
