claim quality analyst

This role is for one of the Weekday's clients

Min Experience: 4 years

Location: Bangalore

JobType: full-time

As a Claims Quality Analyst, you will be responsible for auditing and evaluating healthcare claims to ensure adherence to payer guidelines, internal policies, and federal regulations, including HIPAA. You will play a key role in identifying process gaps, analyzing error trends, and recommending corrective actions to improve overall claims quality and operational efficiency.

Requirements:
Key Responsibilities

• Conduct quality audits and reviews of medical claims adjudication to ensure accuracy, completeness, and compliance with payer policies and regulatory standards.
• Ensure strict adherence to HIPAA guidelines, data privacy requirements, and confidentiality standards across all claim review activities.
• Evaluate claims for correct coding, benefit application, provider eligibility, authorization, and payment accuracy.
• Identify error patterns, root causes, and process deviations, and document findings in clear, structured quality reports.
• Provide actionable feedback to claims processing and adjudication teams to address quality gaps and reduce rework or financial leakage.
• Support the development and maintenance of quality metrics, scorecards, and audit frameworks aligned with organizational goals.
• Collaborate with operations, training, and compliance teams to implement corrective and preventive actions.
• Participate in calibration sessions to ensure consistency in quality evaluations and scoring methodologies.
• Stay current with updates to US healthcare regulations, payer policies, and adjudication guidelines, and apply changes effectively in quality assessments.
• Contribute to continuous improvement initiatives by recommending process enhancements and best practices.

What Makes You a Great Fit

• A minimum of 4 years of experience in US healthcare claims processing, adjudication, or quality analysis.
• Strong working knowledge of HIPAA regulations, medical claims workflows, and payer-specific adjudication rules.
• Proven experience in conducting claim audits, quality reviews, or compliance assessments.
• Solid understanding of US healthcare concepts such as eligibility, benefits, authorizations, coding, and reimbursement methodologies.
• Excellent analytical and problem-solving skills with strong attention to detail.
• Ability to interpret complex guidelines and translate them into clear quality feedback and improvement actions.
• Strong communication skills to collaborate effectively with operations, compliance, and training teams.
• A proactive, quality-focused mindset with the ability to work independently in a fast-paced environment.