Quality Analyst Claims Processing US Medical Billing

Summary

The Quality Analyst (QA) for Claims Processing is responsible for reviewing and validating medical claims prior to submission, ensuring accuracy and compliance with billing guidelines to minimize denials and reduce rework. This role focuses on identifying errors, preventing denials, improving first-pass resolution, and supporting continuous improvement across the RCM workflow. Excellent opportunity for individuals who have a strong foundation in medical billing.

Key Responsibilities:

• Review claims for accuracy before submission
• Validate CPT codes, ICD diagnosis codes, and modifier combinations to ensure correct and compliant billing
• Provide suggestions and recommendations when discrepancies or errors are found.
• Ensure claims meet payer-specific guidelines for clean claim submission.
• Ability to identify unbundling, upcoding, or invalid code combinations
• Strong attention to detail and analytical thinking.
• Collaborate with crossfunctional teams (coding, charge entry, AR, eligibility) to resolve quality issues.
• Suggest automation opportunities or checklist improvements.
• Monitor First Pass Resolution Rate (FPRR) and denial trends.
• Monitor updates from CMS, Medicare, Medicaid, and commercial payers.
• Prepare daily, weekly, and monthly quality reports.

Required Skills & Qualifications:

• Strong knowledge of CPT, HCPCS, ICD10, and payer-specific billing rules.
• Expertise in CPT, HCPCS, ICD10, and modifier usage.
• Familiarity with EOBs, ERAs, clearinghouse rejections, and denial codes.
• Experience with US healthcare payers (Medicare, Medicaid, BCBS, UHC, Aetna, Cigna, etc.).
• Excellent analytical skills with strong attention to detail.
• Strong logical thinking skills to resolve problems and take decisions.
• Ability to interpret medical documentation and provider notes.
• Strong communication skills for feedback, client communication, and team coordination.
• Ability to work in a fast-paced, SLA-driven environment.
• Ability to work independently and collaboratively.

Educational Qualification

• Any bachelors degree (Preferred)
• Diploma or certification in Medical Billing/Healthcare Administration is an added advantage.
• Additional Advantage: Experience in multi-specialty billing (Internal Medicine, Cardiology, Orthopaedics, Radiology, etc.).

Experience

• 3+ years of experience in medical billing, claims processing, or RCM quality auditing.
• Proficiency in Excel for reporting (pivot tables, VLOOKUP, dashboards).