About this role
About the Role We are seeking a Senior Claims Integrity & Quality Analyst to design and execute the quality framework that drives payment accuracy, regulatory compliance, automation, and operational excellence across Curative’s claims ecosystem. This role partners with Claims Operations, Configuration, Product, Compliance, and Technology to identify root causes, eliminate defects, and improve auto-adjudication performance. What You'll Do
- Conduct in-depth audits and clinical reviews of professional, institutional, ancillary, and high-dollar claims, focusing on adjudication accuracy, benefit application, pricing, and coding (ICD-10, CPT/HCPCS, DRG).
- Utilize advanced coding expertise and workflow systems to substantiate audit findings, generate recoverable claims, and investigate potential fraud and utilization patterns.
- Drive operational excellence by validating claims configuration, reimbursement methodologies, and processing logic.
- Support the implementation of automated controls, advanced editing/AI solutions, and workflow enhancements to improve payment accuracy, reduce administrative costs, and contribute to the development of audit tools, policies, and procedures.
- Identify trends, defects, and operational risks impacting claims quality.
- Develop reports and present findings and recommendations to operational leadership to drive corrective actions and improvement opportunities. What We're Looking For
- BA/BS degree in a related field
- Minimum 5 years of experience in healthcare claims auditing, coding auditing, or formal quality assurance program experience
- Broad knowledge of provider billing guidelines, payer reimbursement policies, medical policy guidelines, and commercial insurance plans
- Requires at least one of the following current certifications from AAPC or AHIMA: RHIA, RHIT, CCS, CIC, or CPC
- Minimum 5 years of experience working with ICD-10CM, MS-DRG, AP-DRG, and APR-DRG coding standards
- Experience identifying root causes and driving corrective actions
- Strong analytical and investigative skills Nice to Have
- Health plan or payer-side experience
- Experience with claims configuration validation
- Experience supporting automation initiatives
- Experience working in a high-growth environment
- Clinical nursing with exposure to hospital bill auditing; RN license (unrestricted)
- Proficiency in Google Workspace and experience with audit tracking systems and data analytics tools (Snowflake, Streamlit, Claude) Compensation & Benefits
- Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan)
- $0 copays and $0 deductibles (with completion of Baseline Visit)
- Preventive and primary care built in; mental health support
- One-on-one care navigation; chronic condition programs
- Maternity and family planning support; 24/7/365 Curative Telehealth
- Pharmacy benefits; comprehensive dental and vision coverage
- Employer-provided life and disability coverage with additional options
- Flexible spending accounts; flexible work options: remote and in-person opportunities
- Generous PTO plus 11 paid annual company holidays; 401K for full-time employees
- Generous paid parental leave (8–12 weeks, based on role eligibility)