Controls and QA Analyst
Core
Develop, monitor, assess, and review quality and control procedures for claims processing and benefit design; define performance standards and conduct root-cause analysis.
Role type
Senior IC quality analyst (PBM)
Builds
Internal quality assurance processes, claims processing standards, and reimbursement audit procedures
Domain
Health insurance / Pharmacy Benefit Management (PBM) (via careerplan.io/jobs/Southern-Scripts-Controls-and-QA-Analyst-controls-and-qa-analyst-at-southern-scripts)
Deliverable
dashboards & analysis
Required skills
root-cause analysis, claims processing knowledge, benefit design execution, quality control procedures, performance standard definition, trend analysis, user acceptance testing, HIPAA compliance
Preferred skills
bachelor's degree, five years of QA experience in PBM setting
Technologies
Excel
Responsibilities
Develop and review quality and control procedures for claims processing; define and evaluate performance and quality standards for Claims Processing employees; maintain training and working knowledge of claims processing programs, policies, and systems; assist with group and plan design and manage tickets; conduct root-cause and corrective-action analysis; assist with user acceptance testing and coordinate with external teams on test-platform claims data; analyze test claims and adjudication results to verify configuration accuracy; participate in ongoing claims analysis to ensure daily team work meets quality expectations; follow HIPAA obligations for protected health information.
