Healthcare Claims Quality Analyst

Job Expectations:

• Position Type: Experienced - Mid/Senior
• Employment Type: Full-Time, Permanent (Direct Hire)
• Work Setup & Location: Fully Onsite - Bridgetowne, Pasig/Quezon City
• Work Schedule: Weekdays; Late Night Shift
• Number of Headcounts: 5 FTEs Available
• Industry: Healthcare

About the Job:

We are looking for a detail-oriented Quality Control Analyst to join the team and support the accuracy and integrity of claims processing and reimbursement activities. In this role, you will be responsible for auditing complex and high-dollar claims, identifying processing errors, and ensuring compliance with coding, reimbursement, and contractual guidelines. You will also support special audit projects, including risk pool and health plan reviews, while helping improve system accuracy and operational efficiency. This position requires strong analytical skills, deep knowledge of healthcare claims, and the ability to work independently in a fast-paced environment.

Key Responsibilities:

• Review complex and high-dollar claims to ensure accuracy in coding, reimbursement, and contract application.
• Apply coding and reimbursement guidelines (CPT, ICD-9/10, HCPCS, RBRVS) in claims review.
• Review provider disputes related to denied or incorrect payments.
• Identify and report system issues affecting claims processing and escalate to the appropriate teams.
• Conduct audits of system setup for new clients and contract updates.
• Perform periodic audits of paid claims and flag overpayments for recovery.
• Document audit findings, errors, and recommendations for improvement.

Qualifications:

• Bachelor's degree in Finance, Accounting, or related field.
• 5+ years of experience as a Quality Control Analyst; 2 years of experience as a Claims Adjuster.
• Strong knowledge of managed healthcare operations and claims processing.
• Proficient in medical coding systems (CPT, ICD-9/10, HCPCS) and reimbursement methodologies.
• Skilled in Microsoft Office and claims/audit systems (e.g., EZ-Cap, McKesson Claim Check, DRG tools).
• Ability to work independently in a virtual or minimally supervised environment.
• Possesses excellent interpersonal and communication (written & verbal) skills.
• Can start immediately, if possible.

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