Quality Assurance Examiner

About HPI

Health Plans, Inc. (HPI) has been a trusted leader in the health benefits industry for over 44 years, combining extensive experience with an entrepreneurial spirit. As a third-party administrator, HPI provides comprehensive health and benefit solutions to employers nationwide. The company values integrity, flexibility, loyalty, compassion, and dedication, fostering an inclusive, supportive workplace that encourages innovation and growth.

Role Overview

The Quality Assurance Examiner plays a critical role in auditing claims and ensuring compliance with company policies. This includes conducting both internal and external audits, analyzing claims errors, maintaining accurate documentation, and overseeing interactions with outside vendors to manage payments, recoveries, and adjustments.

Key Responsibilities

• Conduct thorough internal audits of high-value claims and adjustment transactions, including those exceeding $50,000 to $100,000.
• Collaborate with external audit vendors to address queries, provide detailed feedback, and ensure audit accuracy.
• Handle processing of claim adjustments, refunds, recoveries, voids, reissues, and Medicare demand transactions.
• Examine adjustment and refund data to identify patterns, diagnose root causes, and suggest improvements in processes, training, or systems.
• Investigate operational or payment issues, proposing recommendations to senior management.
• Work closely with provider billing vendors to coordinate refunds, adjust claims, and review related audit correspondence.
• Track adjustment activities diligently, keeping precise records and reports.
• Prepare and deliver monthly audit reports highlighting departmental findings and key insights.
• Support ongoing improvement initiatives aimed at increasing accuracy, efficiency, and regulatory compliance in claims and auditing procedures.

Candidate Profile

• Possession of a bachelor’s degree or an equivalent mix of education and professional experience.
• Three to five years experience in claims processing within the healthcare or health insurance sectors.
• Exceptional analytical and problem-solving capabilities with meticulous attention to detail.
• Capacity to balance multiple priorities in a dynamic environment while maintaining precision.
• Strong organizational skills with the ability to meet strict deadlines consistently.
• Effective verbal and written communication skills, suitable for interaction at all organizational levels.
• Able to work independently yet function well within a collaborative team environment.
• Understanding of complex system interactions and the ability to foresee effects of process modifications.
• Reliable in managing assigned tasks, proactively solving problems, and ensuring timely completion.
• Exercising sound judgment and maintaining confidentiality when handling sensitive information.
• Dedicated to continuous professional improvement focused on enhancing quality, accuracy, and operational performance.

Why Join Us?

• We prioritize people and community engagement, offering volunteer opportunities.
• Our work environment promotes openness, innovation, and collaboration.
• Casual, smart attire is welcomed, and workspaces include ergonomic furniture.
• Onsite amenities at our Westborough headquarters include a café, walking trails, and fitness facilities to support well-being.

Benefits

• Comprehensive medical, dental, vision, and prescription drug coverage.
• Fitness reimbursement programs.
• Employee assistance and support services.
• Flexible spending and health savings accounts.
• 401(k) retirement plan with quarterly bonuses.
• Generous paid time off and opportunities for volunteering.
• Educational support and professional development programs.

Equal Opportunity Employer

HPI is an equal opportunity employer committed to a diverse workforce.