Quality Analyst - Payer Enrollment

Job Summary:

The Quality Analyst Provider Enrollment is responsible for ensuring the accuracy, compliance, and completeness of all provider enrollment activities. This role involves reviewing completed transactions, identifying process gaps, providing feedback, and driving continuous improvement to maintain high-quality standards in provider data management and credentialing functions.

Key Responsibilities:

• Conduct quality audits on provider enrollment files and transactions to ensure compliance with payer, state, and organizational requirements.
• Validate provider data accuracy in systems (e.g., NPPES, CAQH, PECOS, payer portals).
• Review new enrollments, revalidations, terminations, and demographic updates for correctness and adherence to SOPs.
• Identify quality issues, root causes, and recurring trends; recommend corrective actions and process improvements.
• Maintain audit logs, prepare quality reports, and track performance metrics (accuracy %, rework %, compliance errors, etc.).
• Collaborate with the Training and Operations teams to address knowledge gaps and provide targeted feedback to staff.
• Support internal and external audits by ensuring documentation readiness and adherence to compliance standards (HIPAA, CMS, NCQA, etc.).
• Participate in calibration sessions to ensure alignment in audit scoring and quality standards.
• Assist in developing and updating audit checklists, SOPs, and training materials.
• Contribute to continuous improvement initiatives focused on accuracy, efficiency, and provider satisfaction.

Required Qualifications:

• Bachelor’s degree preferred (Healthcare Administration, Life Sciences, or related field).
• Minimum 4– 8 years of experience in provider enrollment, credentialing, or provider data management.
• Minimum 2 year of experience in quality auditing or quality assurance within healthcare operations preferred.
• Payer enrollment processes (Medicare, Medicaid, Commercial payers).
• Healthcare provider data elements (NPI, taxonomy, specialties, licensure, etc.).
• Regulatory guidelines and industry standards (CMS, CAQH, HIPAA).

Technical Skills:

• Proficiency in MS Excel and audit tracking tools.
• Experience with provider data systems, CRMs, or workflow tools (e.g., Salesforce, PECOS, or internal platforms).

Key Competencies:

• Strong attention to detail and analytical skills.
• Excellent written and verbal communication.
• Ability to interpret data and identify process trends.
• Good organizational and time management skills.
• Collaborative mindset with the ability to work cross-functionally.
• Commitment to maintaining data integrity and confidentiality.