Job Description

Job Description

Job Description

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 

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