Quality Assurance Specialist - Medical Claims

DATAMARK, Inc. is seeking a detail-oriented Quality Assurance Specialist to join our team. In this role, you will help ensure the accuracy, consistency, and compliance of medical claims processing operations by evaluating performance, identifying trends, and supporting continuous improvement efforts. You will work closely with operations leadership, training, and compliance teams to maintain quality standards and drive operational excellence.

Responsibilities

• Develop and maintain a thorough understanding of quality expectations, performance standards, policies, procedures, and compliance requirements related to medical claims processing.
• Monitor and evaluate processor performance through quality audits and transaction reviews, providing objective feedback and identifying opportunities for improvement.
• Partner with supervisors and operational leaders to support performance improvement initiatives and corrective action plans.
• Analyze quality data and prepare regular reports that highlight trends, areas of risk, and opportunities for process enhancement.
• Publish and communicate quality performance metrics to management and project stakeholders on a regular basis.
• Maintain accurate records of quality reviews, audit findings, corrective actions, and identified issues.
• Support internal and external audit readiness activities, including documentation reviews and compliance assessments.
• Collaborate with Training, Compliance, and Operations teams to investigate quality concerns and implement effective solutions.
• Participate in calibration sessions and quality review meetings to ensure scoring consistency and alignment across teams.

• High school diploma or equivalent required; associate's or bachelor's degree preferred.
• Minimum of 3 years of quality assurance, quality control, auditing, or process improvement experience.

• At least 1 year of experience in a healthcare, medical claims processing, or related operational environment preferred.
• Experience auditing healthcare operations, medical claims processing, eligibility verification, prior authorizations, or related healthcare transactions preferred
• Experience conducting quality audits, analyzing performance data, and driving process improvement initiatives.
• Prior experience in a business process outsourcing (BPO), customer operations, healthcare services, or similar environment is preferred.
• Working knowledge of quality management principles, audit methodologies, and continuous improvement practices.
• Strong analytical and problem-solving skills with the ability to identify trends, root causes, and opportunities for improvement.
• Excellent written and verbal communication skills, including the ability to provide constructive feedback and present findings to stakeholders.
• Strong attention to detail and ability to maintain accuracy while managing multiple priorities.
• Proficiency with Microsoft Excel and reporting tools used to track, analyze, and communicate quality performance metrics.
• Ability to collaborate effectively with cross-functional teams, including Operations, Training, and Compliance.
• Ability to adapt to changing business needs and work effectively in a fast-paced environment.

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources