Quality Assurance Specialist - Healthcare Payer Industry

Quality Assurance Specialist

Smart Data Solutions, a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, is looking for a Quality Assurance Specialist to join our team!

What you’ll be doing?

Duties & Responsibilities

• Provides analysis of business specifications and requirements, interfaces with clients and internal departments and provides support to the team.
• Handles a diverse range of issues that require evaluating a variety of factors, including current business trends.
• Conducts complex transactional quality audit based on audit parameters.
• Develop, implement, and maintain comprehensive quality audit programs, including detailed audit plans, checklists, and reports.
• May perform quality audits on related administrative operations work in support of client services delivery.
• Performs analysis on escalated and increasingly complex business process problems and circumstances to understand client transactions in order to recommend process improvements and/or solutions.
• Identify, document, and report defects or issues found during testing, ensuring they are accurately tracked and resolved.
• Collaborate closely with developers, product managers, and other stakeholders to address issues and improve product quality.
• Develop, implement, and maintain detailed test plans, test cases, and testing strategies based on project requirements and specifications.
• Plan, execute, and oversee audit assessments and testing for assurance and conformance to policies and procedures, contracts, and/or business requirements, validating accuracy of translation and completeness.
• Facilitate and oversee corrective action initiatives to improve operations, operating procedures, and overall accuracy of results/outcomes.
• Support root cause analysis procedures, maintain corrective action plan catalogue, and report obstacles/challenges to department leadership, compliance, and other stakeholders.
• Performs analyses of data/metrics to identify trends as well as areas of immediate concern and escalates to management attention, as necessary.
• Lead or participate in external audits, inspections, and certifications as required.
• Perform other duties as assigned.
  
  

The duties set forth above are essential job functions for the role. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

What we’re looking for?

Required Skills & 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 3 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.
  
  

Location: This role is located in our Dallas office (Plano, TX). This is a hybrid position with 3 days in-office requirements.

Why this is the company for you?

Top Benefits & Perks

• A company culture that is authentic, innovative, and collaborative! Our most powerful strength is our people! We build impactful solutions for our customers - their success is our success!
• A professional development and growth-oriented workplace
• Generous benefits including, health insurance, short-term, and long-term disability
• 401(k) with a company match to provide a better future in your retirement years
• A flexible environment with a competitive paid time off package; including vacation, holiday, give-back day, and a floating day
  
  

Who is Smart Data Solutions?

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.

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.