Claims Quality Assurance Analyst - TPA

Network Health's success is deeply rooted in our mission to build healthy and strong Wisconsin communities. This mission guides every decision we make, including the selection of individuals who join our growing team.

The Claims Quality Assurance Analyst - TPA plays a critical role in supporting operational excellence, claims accuracy, and regulatory compliance. This position conducts quality audits, reviews, and monitoring of claims and operational data to identify trends, inefficiencies, and opportunities for improvement. The Analyst ensures adherence to established quality standards, regulatory and contractual requirements, and operational procedures while supporting accurate, efficient, and consistent claims processing practices that promote high-quality service and outcomes for members and providers.

The position also performs internal audit activities and supports Internal Audit in fulfilling requirements related to Model Audit Requirements (MAR), Service Level Agreements (SLAs), and other applicable audit and compliance standards. Through the analysis of audit findings and operational data, the Analyst identifies root causes, recommends corrective actions, and contributes to continuous improvement initiatives.

This role collaborates regularly with subject matter experts and cross-functional partners throughout Network Health to investigate and resolve complex claims payment and processing issues. The Analyst applies and interprets company reimbursement policies, Desk Level Procedures (DLPs), Summary Plan Descriptions (SPDs), Administrative Services Agreements (ASAs), CMS regulations, provider contracts, and other applicable resources to determine accurate and appropriate claims payment outcomes.

As a subject matter resource for claims quality and accuracy, the Claims Quality Assurance Analyst helps strengthen processes, reduce errors, improve operational performance, and maintain consistent compliance with applicable requirements. Through these efforts, the position supports the delivery of reliable, high-quality claims services to our members and providers.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required) in combination with at our office in in our hybrid workplace model.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities

• Demonstrate commitment to and behavior aligned with the philosophy, mission, values, and vision of Network Health.
• Appropriately apply organizational, regulatory, contractual, and operational principles, procedures, requirements, regulations, and policies.
• Perform data entry, claims, enrollment, and operational monitoring activities in accordance with established criteria, methodologies, and timelines.
• Review medical claims, supporting documentation, and medical records, as applicable, to evaluate completeness, accuracy, appropriate payment, and compliance with applicable policies, procedures, contractual requirements, and regulatory standards.
• Conduct claims quality audits and monitoring activities to identify payment discrepancies, processing errors, trends, and opportunities for improved accuracy, efficiency, and consistency.
• Analyze audit and operational results to identify trends and root causes of identified issues and develop meaningful, actionable recommendations for process improvement.
• Compile, document, and communicate audit and monitoring results to leadership and appropriate team members, including identified discrepancies, trends, risks, and recommended corrective actions.
• Ensure monitoring and audit activities are completed accurately and timely in accordance with established schedules, standards, and requirements.
• Maintain accurate and current tracking databases, audit tools, documentation, and files to support quality monitoring and reporting activities.
• Run, review, and compile daily claims inventory reports required to conduct audits and monitoring activities; request and coordinate custom claims reports as needed.
• Support claims audits and monitoring activities related to Service Level Agreements (SLAs), including tracking results and identifying opportunities to improve compliance and performance.
• Assist Internal Audit with applicable Model Audit Requirements (MAR) functions by performing assigned audit, monitoring, research, documentation, and reporting activities.
• Review and provide feedback on Desk Level Procedure (DLP) documents to help ensure procedures accurately reflect current claims processing practices, requirements, and processes.
• Research and collaborate with subject matter experts and appropriate internal departments to resolve claims quality issues and determine accurate and appropriate payment outcomes.
• Maintain strong working relationships with internal and external contacts and consistently demonstrate professionalism, accountability, adaptability, and a commitment to exceptional service.
• Support department initiatives, projects, and teammates as needed and contribute to the achievement of overall department goals and objectives.
• Identify and communicate opportunities to improve claims processes, quality, accuracy, and operational efficiency.

Job Requirements:

• High school diploma or equivalent
• 2 or more years working in an auditing or claim payment accuracy focused role required.
• 2 or more years of experience in health care required.

Network Health is an Equal Opportunity Employer