Quality Review Analyst – Claims (Remote)

American Specialty Health Incorporated is seeking a Quality Review Analyst to join our department. This position will perform audit and quality review processes in accordance with Claims Department Policy & Procedures.

Hourly Salary Range

American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $14.70 to $17.00 Hourly Wage Range.

Remote Worker Considerations

Candidates who are selected for this position will be trained remotely and must be able to work from home in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and10 Mbps upload speed).


Coordinates and conducts quality review of claims processing.
Conducts random quality review daily.
Conducts Contract Approval audits including Client Summaries and Fee Schedules.
Prepares and presents feedback on deficiencies identified in accuracy, timeliness, or quality to Claims Supervisor.
Identifies unique issues and problems within assigned areas of responsibility. Researches and formulates solutions in conjunction with Claims Supervisor.
Analyze and validate claim audits, health plan and state specific reporting.
Processes claims requiring special handling.
Reviews and releases aged claims on daily Pend Report.
Performs audit on new staff to ensure 100% accuracy.
Maintains confidentiality of all claims files, audit reports, and related claims data.
Develops and maintains reporting guidelines and specifications.
Prepare standardized weekly and monthly KPI reports.
Prepares applicable reports necessary to complete the KPI Reports.
Prepares and distributes daily reports to leadership, including but not limited to no-line items, pended claims, and 10-day TAT.

High School Diploma required.
Achieved progression to Level II Claims Examiner for internal Claims candidates, or minimum 2 years of experience performing claims processing or analyst/research duties.
Must be able to type 10,000 keystrokes per hour, either alpha-numeric or numeric with 95% accuracy or higher.
Advanced experience with MS Word, Excel and Access.
Knowledge of managed care operations, accreditation guidelines and state requirements.
Strong analytical and problem-solving skills.
Core Competencies

Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
Ability to effectively organize, prioritize, multi-task and manage time.
Demonstrated accuracy and productivity in a changing environment with constant interruptions.
Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
Ability to exercise strict confidentiality in all matters.

Primarily sedentary, able to sit for long periods of time.

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.

Environmental Conditions

Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex including sexual orientation and gender identity, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.