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About The Role

Brighton Health Plan Solutions is seeking a Senior Quality Analyst, who will oversee contract and benefit configuration to ensure accurate claims processing and network compliance. This is a remote role.

Primary Responsibilities

+ Audit system configuration against contract requirements.

+ Identify fee schedule, provider rate, and benefit setup discrepancies.

+ Collaborate with IT and operations to resolve claims configuration gaps.

+ Perform routine and complex audits of claim transactions processed within our Production and QA regions to validate results.

+ Detailed review of internal and external reporting.

+ Support quarterly claim audits and updates.

+ Assess the impact of configuration changes by processing claim adjustments, manual claim entry, void-reissue of payment, etc.

+ Support new client implementations by validating benefits and claims logic were loaded correctly.

+ Develop and prepare reporting results of findings from process audits and testing.

+ Assisting in identifying the root cause of errors inline to system configuration vs manual processing.

+ Help identify solutions for system issues impacting claim processing results.

+ Provide audit feedback to the claim's leadership team when a need for group and/or individual training has been identified.

+ Perform focus audits, create ad hoc reports and summarize results for management and/or client.

Essential Qualifications

+ 5+ years of advanced claims adjudication experience including facility, professional and ancillary claims.

+ Minimum 3 years in auditing of claims adjudication.

+ Working knowledge of medical terminologies and coding a plus

+ Excellent written and oral communication, interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required.

+ Experience with building and running SQL queries

+ Problem solving/analysis.

+ Strong organizational skills: ability to effectively prioritize and multitask.

+ MS Office (Word, Excel, Outlook and PowerPoint).

+ Strong analytical aptitudes, communication and comprehension capabilities.

+ Enthusiastic attitude, cooperative team player, adaptable to new or changing circumstances.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

*We are an Equal Opportunity Employer

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