Quality Control Analyst

Position: Quality Control Analyst 

Department: Corporate Stop Loss 

Reports To: Manager, Quality & Process Optimization

FLSA Status: Non-Exempt

Health Plans, Inc. (HPI) is a New England-based Third Party Administrator (TPA) of self-funded health and benefit plans. HPI was founded in 1981 to provide comprehensive health plan administration to employers, municipalities and Taft-Hartley plans. Health Plans has grown to become an industry-leading TPA by offering customized self-funded benefit plans to employers, combined with superior customer service and investment in the latest administrative and data-mining technology, and reinsurance (stop-loss) security.

Summary:

The Quality Control Analyst is responsible for ensuring the accuracy and compliance of financial operations related to claims funding, billing, and financial operations related to stop loss claims and other financial products. 

The analyst will be expected to collaborate with operational teams to develop and implement quality control procedures and best practices aimed at enhancing efficiency and accuracy. 

They will be responsible for conducting audits, performing data analysis, and developing statistical reports for all department activities to appraise data accuracy.

Duties and Responsibilities (other duties may be assigned):

• Conduct regular audits of financial transactions related to claims funding, billing, and stop loss submissions processed by the teams to ensure adherence to industry regulations and internal policies & procedures
• Review and analyze reports to identify discrepancies, errors, or trends that may impact financial performance 
• Support all external audit requests and audit of materials gathered prior to submission 
• Maintain accurate and organized records of all quality control activities, including audit results, corrective actions taken, and follow-up measures
• Act as a subject matter expert for projects aimed at process improvement and operational excellence
• Recommend process changes based on audit findings and industry standards to improve overall service delivery
• Prepare detailed reports summarizing findings and presenting them in a clear and actionable format to management
• Participate in cross-functional meetings to discuss quality issues and propose solutions
• Accountable for reaching target metrics related to quality & performance improvements
• Assist in the development of departmental policies and procedures
• Provide training and support to staff on quality control processes and compliance requirements
• Assist with researching and resolution of client issues

• Assess the need for a sense of urgency with all work activities and communicate appropriately with department leadership to coordinate response/resolution.

Minimum Education Requirements:

• Associate’s degree or equivalent work experience

Minimum Experience Requirements:

• Previous experience in quality control, auditing, or compliance within the finance or healthcare insurance sector
• Strong analytical skills and high attention to detail and accuracy
• Strong organizational skills with the ability to manage multiple priorities
• Work within specified timeframe and meet deadlines.
• Strong customer service orientation and ability to build relationships.
• Excellent knowledge of MS Office & proficient in data analysis tools and software (e.g. Excel, SQL)
• Effective verbal and written communication skills; experienced in collaborating with internal teams, vendors, and customers to resolve inquiries

Preferred Education Requirements:

Preferred Experience Requirements:

• 1+ years of experience in stop loss administration, self-funded health plans, finance operations, or a related role within a TPA, carrier, or benefits administration environment.
• Strong understanding of claims funding and stop loss workflows and financial controls.<