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Role Description

MedReview is looking for a skilled Quality Analyst to join our Payment Integrity team, specializing in Healthcare Claims Data Mining. The ideal candidate will be responsible for ensuring the quality and accuracy of healthcare claims data, particularly related to post-pay overpayment analysis. This role requires a strong background in healthcare claims processing, data mining, and quality assurance, along with excellent organizational and communication skills.

• Conduct thorough quality assessments of healthcare claims data, focusing on identifying overpayments through data mining techniques.
• Develop, implement, and execute quality assurance plans and test cases specific to healthcare claims data mining.
• Collaborate with data analysts and business partners to analyze claims data for potential overpayments and ensure compliance with client policies.
• Identify and document any discrepancies or anomalies in claims data, coordinating with cross-functional teams for resolution.
• Conduct root cause analysis on detected overpayments and develop reports summarizing findings and recommendations for process improvements.
• Monitor and evaluate data mining processes, providing innovative solutions to enhance data accuracy and quality assurance in healthcare claims.
• Prepare and present detailed quality assurance reports and metrics to stakeholders, highlighting trends and areas for improvement.
• Foster strong working relationships with various business partners, ensuring effective communication and collaboration on claims data integrity initiatives.

Qualifications

• High school diploma and or an advanced degree or certifications in Healthcare.
• Minimum of 5 years of experience in healthcare claims processing, data mining, or related roles, with a specific focus on post-pay overpayment analysis.
• Proven experience in quality assurance processes and methodologies, particularly in the context of healthcare claims data.
• Proficiency in O365 applications (Excel, Word, PowerPoint, Teams) for data management and report generation.
• Strong understanding of healthcare claims regulations, compliance standards, and payment integrity processes.
• Excellent analytical and problem-solving skills with the ability to interpret complex claims data.
• Effective communication and interpersonal skills, with experience collaborating with multiple business partners.
• Knowledge of coding schemes such as CPT, ICD-10, and HCPCS is beneficial.
• Experience working with and interpreting medical reimbursement and CMS policy is required.