Quality Assurance Analyst

Quick Facts

• Work Policy: Remote (United States)
• Job Type: Full Time (40 hours/week)
• Experience Level: 5-7 years of direct experience minimum
• Education: High school diploma

About Tango

Tango is a leader in the home health management industry and is preparing for significant growth. The company’s mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes, partnering with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

About the Role

Tango is looking for a Quality Assurance Analyst to join its growing team. This isn’t a software-testing QA role; it’s a claims-focused quality assurance position centered on auditing healthcare claims data for accuracy, compliance, and financial correctness across the company’s health plan partnerships.

What You’ll Do

At the core of the role, you’ll validate claims data against information from claims processing systems to confirm it’s accurate, covering both auto-adjudicated claims and claims that were processed manually. You’ll analyze claims data against applicable policies and regulations to catch potential issues such as member benefit discrepancies, billing anomalies, payment accuracy problems, or claims processing system issues, and you’ll review the history of related claims to pull in and understand additional context before making a determination.

When you find errors or defects, you’ll calculate the dollar amount involved and develop fact-based audit determinations that you deliver in an objective, non-confrontational way. Issues identified during the audit cycle or rebuttal process get escalated to the right stakeholders, whether that’s the Operations Team or the Quality Team, and you’ll make sure audit and rebuttal timelines are followed, including rebuttal timelines, form completion, workflows, and turnaround time.

You’ll be expected to hit production quality goals and metrics, such as audits per hour, audit accuracy, first-pass accuracy, and rebuttal accuracy, while providing supporting documentation for your audit findings. When errors or defects get escalated, you’ll help identify, communicate, and ensure they’re properly resolved, whether through rebuttals or appeals, and you’ll communicate audit findings clearly to stakeholders, including error descriptions and rebuttal information.

Beyond individual audits, you’ll identify and help implement opportunities to improve the Quality team’s internal audit and rebuttal processes, and you’ll need to identify, interpret, and apply the claims and audit policies and procedures that govern the work. That means understanding how different factors can affect claims accuracy, such as system edits, keying vendor discrepancies, or system logic, along with general knowledge of the healthcare industry: billing practices, terminology, legal and regulatory requirements, and coding standards. You’ll also identify and interpret applicable plan benefit information from contracts, maintain claims policies, procedures, and job aids to stay within compliance annually, oversee the annual vendor compliance process, support ad hoc provider audits on a quarterly basis, and support records requests or subpoenas in coordination with the Compliance team.

On the broader essential duties side, you’ll oversee quality and findings across internal and external audits, covering all vendors and staff accuracy, and take on other duties as assigned within the scope of the role.

• Validate claims data against claims processing systems for accuracy, covering both auto-adjudicated and manually processed claims
• Analyze claims data against applicable policies and regulations to identify potential issues (member benefits, billing anomalies, payment accuracy, system issues)
• Review the history of related claims to gather and understand additional claims-related information
• Calculate the dollar amount of financial claims errors/defects
• Develop and deliver fact-based audit determinations in an objective, non-confrontational manner
• Escalate issues identified during the audit cycle or rebuttal process to the appropriate stakeholders
• Ensure compliance with applicable audit and rebuttal timelines, workflows, and turnaround time
• Achieve production quality goals and metrics (audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
• Provide supporting documentation for audit findings
• Identify and communicate escalated errors/defects and ensure proper resolution (rebuttals, appeals)
• Communicate audit findings to applicable stakeholders, including error descriptions and rebuttal information
• Identify, communicate, and implement opportunities for improving internal audit/rebuttal processes within the Quality team
• Identify, interpret, and apply applicable claims and audit policies and procedures
• Understand how various factors impact claims accuracy, such as system edits, keying vendor discrepancies, and system logic
• Apply knowledge of the healthcare industry, including billing practices, terminology, legal/regulatory requirements, and coding standards
• Identify and interpret applicable plan benefit information from contracts
• Maintain claims policies, procedures, and job aids to stay within compliance annually
• Oversee the annual vendor compliance process
• Support ad hoc provider audits on a quarterly basis
• Support records requests and subpoenas in coordination with Compliance
• Oversee quality and findings in internal and external audits across all vendors and staff accuracy

What You’ll Need

Tango is looking for 5-7 years of direct experience minimum, with an advanced level of skills and knowledge of technical system operations, plus a solid understanding of enrollment and eligibility as well as claims paying across all lines of business. Candidates should have professional-level training that provides a general understanding of the administration of contractual obligations, audit and billing procedures, policies and procedures, how accounts receivable processing and eligibility requirements affect claims processing, vendor data feeds and the discrepancy process, administrative and regulatory requirements, technical workflow processes, the functional requirements of the claims system, and solution design documents.

On top of that, 4-6 years of work experience is expected that provides a working knowledge of claims billing and delinquency procedures, the accounts receivable process, system testing and enhancement processes, and web portal data support.

• 5-7 years of direct experience minimum
• Advanced level of skills and knowledge of technical system operations
• Solid understanding of enrollment and eligibility as well as claims paying for all lines of business
• Professional-level training covering contractual obligations administration, audit and billing procedures, policies and procedures, accounts receivable/eligibility impacts on claims processing, vendor data feeds and discrepancy process, administrative and regulatory requirements, technical workflow processes, functional system requirements, and solution design documents
• 4-6 years of work experience providing a working knowledge of claims billing and delinquency procedures, the accounts receivable process, system testing and enhancement process, and web portal data support

Skills and Abilities

• Advanced-level Microsoft Office skills (PowerPoint, Word, Outlook)
• Advanced-level Microsoft Excel skills
• Interpersonal, communication (written and verbal), and presentation skills
• Analytical, research, problem-solving, and decision-making skills
• Ability to monitor team goals
• Ability to lead and coach team members