Healthcare Claims Quality Assurance Specialist

Cobalt Benefits Group is seeking a detail-oriented Quality Assurance Specialist to support our healthcare vertical clients through comprehensive claims auditing and quality oversight. This role is primarily responsible for conducting daily audits of medical claims to ensure accurate benefit administration, correct provider network tiering, and appropriate contract pricing. The Quality Assurance Specialist plays a critical role in maintaining payment accuracy, identifying process improvement opportunities, and supporting operational excellence across Claims & Service Operations.

Responsibilities

• Perform daily pre-pay and post-pay audits of medical claims.
• Validate benefit application, including deductibles, copays, coinsurance, eligibility, and plan provisions.
• Audit provider network tiering and reimbursement accuracy.
• Verify claims are processed according to provider contracts, fee schedules, and client plan designs.
• Identify, document, and communicate claim processing errors and trends.
• Conduct production, system configuration, and operational quality audits.
• Complete LDLA (Licensee Desk Level Audit) and MTM (Member Touchpoint Measurement) reviews.
• Support external client, regulatory, and internal audit activities.
• Participate in new client, renewal, and plan change testing efforts.
• Produce audit reports and recommend corrective actions and process improvements.
• Collaborate with Claims, Provider Maintenance, Customer Service, Configuration, and Implementation teams to resolve quality issues.