Quality Assurance Specialist

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability. As a strategic partner, SDS helps clients digitally transform their operations, delivering tangible value through reduced costs, streamlined workflows, and an improved customer experience. With data, AI, and automation at its core, SDS provides solutions in Digital Mailroom and Data Capture, Clearinghouse, Intelligent Medical Records, Prior Authorization and Claim Operations. Trusted by over 500 clients—including multiple Blue Cross Blue Shield plans, regional health plans, TPAs, providers, and healthcare partners—SDS streamlines complex front, middle, and back-office operations.

What you’ll be doing?

• Analyze business specifications and requirements; collaborate with clients and internal teams to ensure alignment and provide ongoing support to project.
• Monitor and respond to quality concerns submitted through the Salesforce quality queue, conducting thorough research, resolving issues, and performing trend analysis to identify recurring problems and drive improvements.
• Conduct in-depth quality audits of complex transactions based on established audit parameters and criteria.
• Perform quality reviews of administrative operations and support services to ensure compliance and service excellence in client delivery.
• Investigate escalated and complex business process issues to understand transaction flows, identify root causes, and recommend actionable process improvements.
• Identify, document, and track defects or discrepancies uncovered during audits or testing, ensuring timely resolution and closure.
• Collaborate cross-functionally with developers, product managers, and other stakeholders to resolve issues and enhance product and process quality.
• Plan, execute, and oversee audit assessments to ensure adherence to internal policies, external regulations, contractual obligations, and business requirements.
• Lead and facilitate corrective action initiatives to improve operational procedures, drive process efficiency, and enhance accuracy of results.
• Support root cause analyses, maintain a corrective action tracking system, and communicate barriers or risks to leadership and relevant stakeholders.
• Analyze performance data and key metrics to identify trends, highlight critical areas of concern, and escalate issues as needed.
• Perform other duties as assigned.

What we’re looking for?

Qualifications:

• Bachelor’s degree in Business Administration, Healthcare Administration, or a related field; equivalent professional experience may be considered in lieu of a degree.
• Minimum of 5 to 7 years of experience in quality assurance, auditing, or a related role within the healthcare industry.
• Solid understanding of healthcare industry regulations, standards, and compliance requirements.
• Demonstrated experience conducting internal and external audits, including development of comprehensive audit reports and actionable recommendations.
• Proven ability to analyze data effectively to identify trends, discrepancies, errors, and areas of noncompliance.
• Strong analytical thinking, deductive reasoning, and root cause analysis skills.
• Proficient in Microsoft Office Suite, particularly Excel, Word, and PowerPoint.
• Hands-on experience reviewing and interpreting medical claim forms, including HCFA, CMS-1500, UB-04, and ADA.
• In-depth knowledge of claims processing, prior authorization workflows, denials, and appeals processes.
• Familiarity with medical code sets including ICD-10, HCPCS, CPT, and applicable modifiers.
• Excellent written and verbal communication skills, with the ability to present complex findings clearly and effectively to stakeholders and senior leadership.
• Exceptional attention to detail and the ability to manage multiple priorities and deadlines in a fast-paced environment.
• Ability to work independently with minimal supervision, while also collaborating effectively as part of a cross-functional team.
• Experience with Electronic Data Interchange (EDI), including familiarity with 837/835 files and X12 standards, is a plus.

Smart Data Solutions is an equal opportunity employer.

All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status.