Quality Assurance Specialist

Overview

Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready to Safeguard Claims Integrity Through Expert Quality Assurance?

We're seeking a detail-oriented professional who can maintain the integrity of the claims process through comprehensive auditing and quality assessment. As our Claims Quality Auditor, you'll review internal procedures, processes, and controls to ensure accurate final payments while analyzing claims data to identify incorrectly paid claims and driving corrective actions that improve overall performance.

What makes this role different

✓ Quality assurance leadership: Establish highly effective Internal Audit and Corrective and Prevention Action program with Quality leadership

✓ Performance improvement focus: Monitor performance and support implementation of changes that improve production processes and reduce errors

✓ Data-driven insights: Formulate and maintain department key performance measurements while reporting findings to management

✓ Process optimization: Identify defects and improve departmental performance by supporting quality, operational efficiency, and production goals

What You'll Actually Do

Conduct quality assessments: Record and track quality assessment scores while providing feedback to reduce errors and improve processes and performance across claims operations.

Monitor and improve performance: Track departmental performance and support efforts to develop and implement changes that enhance production processes and quality outcomes.

Lead audit programs: Work with Quality leadership to establish highly effective Internal Audit and Corrective and Prevention Action program ensuring systematic quality control.

Identify and resolve defects: Analyze claims data to identify incorrectly paid claims while working with claims department to implement corrections and prevent recurrence.

Support quality systems: Assist with document control development related to QA system while providing support to other QA Auditors as needed.

Manage performance metrics: Formulate and maintain department key performance measurements while reporting findings to department management for strategic decision-making.

Ensure compliance excellence: Maintain privacy and security of PHI (Protected Health Information) as outlined in HIPAA policies while ensuring privacy of QA statistics for Claims staff.

Meet performance standards: Achieve established timeframes and rates of performance for quality and quantity of work while maintaining extreme accuracy and attention to detail.

Foster positive relations: Practice excellent customer service principles including positive attitude and helpful approach while completing additional tasks assigned by Manager.

Qualifications

What You Bring to Our Team

What You Bring to Our Mission

The foundational experience:

• High school diploma
• Healthcare/Claims processing experience required
• Experience in HealthPac or Javelina claims processing systems preferred

The technical expertise:

• Knowledge of medical terminology; ICD-9, CPT & HCPCS coding
• Proficiency in Word, Excel, and Outlook
• Understanding of claims processing systems and workflows

The quality competencies:

• Good time management skills with highly organized, detail-oriented approach and extreme accuracy
• Effective and professional communication ability, written and verbal skills
• Demonstrate ability to work independently with excellent judgment
• Ability to organize, prioritize, and multitask in fast-paced, deadline-driven environment

The professional qualities:

• Strong analytical skills for reviewing claims data and identifying patterns of incorrectly paid claims
• Capability to provide constructive feedback that reduces errors and improves processes
• Understanding of HIPAA compliance requirements and commitment to maintaining PHI privacy and security
• Collaborative approach to working with claims department staff on corrections and process improvements
• Attention to quality assurance best practices and document control systems
• Customer service orientation with positive attitude and helpful approach to internal stakeholder relationships

Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.