Configuration and Quality Audit Manager

Role Overview

• Build, lead, and mature the claim configuration quality audit function, including audit planning, methodology, governance, quality standards, reporting, and remediation oversight.
• Develop and maintain a risk-based audit plan that prioritizes claim configuration and reimbursement risks based on volume, dollar exposure, provider type, line of business, regulatory or contractual commitments, recent configuration activity, and known issue patterns.
• Establish claim configuration audit programs, sampling logic, testing protocols, workpaper standards, quality review expectations, issue rating criteria, and documentation requirements.
• Oversee routine, targeted, and risk-based audits and analyses of provider pricing configuration and claims across multiple lines of business, products, and provider types.
• Ensure claim processing outcomes are validated against provider contract terms, fee schedules, reimbursement methodologies, benefit or business rules, and applicable federal and state requirements.
• Review and approve audit scopes, test plans, workpapers, findings, root-cause conclusions, financial impact analyses, and remediation validation results.
• Own or oversee issue logs, corrective action plans, remediation milestones, validation plans, and closure evidence for identified claim configuration and payment defects.
• Monitor remediation effectiveness, recurring issue patterns, and control performance and escalate barriers, delays, or unresolved risks to appropriate leadership.
• Lead the design of an analytics strategy used to detect outliers, trends, variances, root causes, and potential payment defects within claims, provider, contract, and configuration data.
• Oversee the development and maintenance of dashboards, scorecards, recurring reporting, databases, data extracts, and audit samples used to monitor claim payment accuracy and remediation effectiveness.
• Manage, coach, and develop analysts responsible for claim configuration audits, payment validation, data analysis, issue documentation, and remediation tracking; assign work, monitor productivity, and ensure timely completion and consistent quality across all audit activities and deliverables; provide technical guidance, peer review, and feedback to ensure findings are well-supported, consistently documented, and appropriately risk rated.
• Translate complex claim configuration, reimbursement, and data findings into clear business narratives and actionable recommendations for technical and non-technical audiences.
• Present audit results, quality trends, risk ratings, financial exposure, corrective action status, and recommendations to leadership and cross-functional workgroups, governance meetings, and forums.
• Continuously evaluate audit coverage, control gaps, and emerging risks and adjust priorities to support organizational objectives and regulatory or contractual requirements.
• Provide subject matter expertise on provider contract reimbursement language, claims adjudication logic, configuration controls, and expected system outcomes.
• Recommend and influence process, control, system, training, and workflow improvements to strengthen configuration accuracy and prevent recurring defects.
• Build effective working relationships with business, technical, finance, compliance, contracting, and leadership stakeholders to support issue resolution and control improvement.
• Partner with IT, Analytics, Finance, and operational leaders to improve data access, automate recurring analyses, strengthen reporting reliability, and support scalable monitoring.
• Promote a culture of accountability, documentation discipline, quality, and continuous improvement across the audit function and partner teams.
• Create and maintain policies, procedures, audit playbooks, training materials, and standard work products for the function.
• Perform other projects and duties as assigned.

Requirements

• Bachelor's degree from an accredited institution or equivalent combination of education and relevant work experience.
• Six or more years of experience with claim payment auditing, claims and provider configuration, payment integrity, contract implementation, or quality assurance in a health plan or managed care environment.
• Two or more years of people leadership, team lead, supervisory, audit project lead, or equivalent experience directing work, reviewing deliverables, coaching staff, and managing priorities.
• Experience with Health Edge Source and/or Health Rules Payer systems.
• Advanced knowledge of healthcare claims processing, including claim adjudication concepts, provider contract concepts, reimbursement methodologies, configuration controls, benefit or business rules, and common claim resolution practices.
• Knowledge of medical terminology and healthcare coding sets, including CPT, HCPCS, ICD-10, revenue codes, modifiers, place-of-service codes, and reimbursement groupers as applicable.
• Experience with facility reimbursement methodologies such as DRG, APC, APG, per diem, percent of charge, case rate, bundled payment, carve-out, stop-loss, or other contractual arrangements.
• Understanding of physician/professional, ancillary, behavioral health, long-term care, or other non-facility reimbursement and billing principles.
• Experience leading data analysis, identifying trends, conducting root cause analysis, quantifying financial or operational impact, and preparing reports for leadership.
• Strong written, verbal, and presentation skills with the ability to communicate clearly with executive, business, technical, and operational audiences.
• Strong organizational, prioritization, and decision-making skills, including the ability to manage competing audits, escalations, analyses, remediation activities, and deadlines.
• Strong interpersonal skills and ability to establish effective working relationships across departments.
• Ability and willingness to learn new technical, operational, and regulatory information.
• Ability to work a hybrid work schedule consisting of reporting to 100 Church Street, NYC every Tuesday, Wednesday and Thursday.

Benefits

• medical, dental and vision coverage
• incentive and recognition programs
• life insurance
• 401k contributions