Hiring: Claims Quality Business Analyst Company: Doctors HealthCare Plans, Inc. Location: Coral Gables, FL Job Posted Time: 2026-09-17 14:48:25 Employment Type: Contract Target Skills & Keywords : Business Analysis, Medicaid, Medicare, Microsoft Excel, Regulatory Compliance, Six Sigma About the job Experience: •3–5 years of health plan claims operations, business analysis, or healthcare analytics experience. •Strong analytical and reporting skills. Required Skills: •Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements. •Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes. •Identify trends related to pended, denied, adjusted, and overturned claims. •Develop and maintain claims quality monitoring reports and dashboards. •Ensure claims communications accurately communicate payment decisions, denial rationale, member responsibility, provider responsibility, and applicable benefit or payment explanations. •Gather business requirements for system enhancements and claims operational improvements. •Analyze claims workflows and recommend process improvements to increase efficiency and reduce rework. •Partner cross-functionally with IT, Delegates and providers/vendors on claims system configuration, testing, and implementation activities. Qualifications: •Knowledge of encounter data reporting and MA organization requirements. •Lean Six Sigma or process improvement experience. •Knowledge of Medicare Advantage claims payment methodologies. •Understanding of claims adjudication and provider reimbursement concepts. •Advanced Excel and data analysis skills. •Demonstrated capacity to analyze large data sets and identify operational trends. •Strong verbal and written communication skills. •Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. •No Third Party Agencies or Submissions Will Be Accepted. •Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!