Configuration and Quality Audit Analyst

Role Overview

• Responsible for managing, administering and governing the Office 365 global tenants, including SharePoint Online, MS Teams, OneDrive and other applications within the Office365 suite
• Work in a dedicated team focused on enterprise collaboration
• Perform routine, targeted, and risk-based audits of provider pricing configuration and claims across multiple lines of business, products, and provider types
• Interpret provider contract reimbursement language and translate terms into expected system outcomes for claims audit testing
• Validate claim processing outcomes against provider contract terms, fee schedules, reimbursement methodologies, benefit or business rules, and applicable federal and state requirements
• Review technical specifications, configuration documentation and reimbursement policy to confirm business requirements and provider contract provisions are accurately implemented
• Identify configuration defects, claim adjudication variances, underpayments, overpayments, quality gaps, and operational control failures
• Analyze claim, provider contract, and configuration data to detect outliers, trends, variances, and root causes
• Conduct financial and operational impact analyses for identified defects, including affected claim volume, dollars at risk, provider or member impact, lines of business, and remediation scope
• Use Excel and query tools to manage large data sets, standardize reports, prioritize audit targets, perform reconciliations, and summarize actionable findings
• Prepare recurring and ad hoc reports on audit results, defect trends, quality performance and remediation status
• Prepare clear audit workpapers, written findings, summaries, and recommendations that adequately support conclusions and remediation actions
• Work directly with business units and technical teams as a subject matter resource on claims configuration, provider reimbursement, claims processing, audit findings, and operational dependencies
• Validate remediation activities and retest as necessary to confirm sustainable resolution
• Support management decision-making by identifying trends, escalating barriers, and presenting concise analyses and recommendations
• Maintain knowledge of supported operational areas, risk landscape, financial impact drivers, processes, controls, and performance standards
• Perform other projects and duties as assigned

Requirements

• Bachelor's degree from an accredited institution or equivalent combination of education and relevant work experience
• At least three years of experience in a managed care organization, commercial health plan, government program, third-party administrator, or other healthcare operations environment performing claims analysis, configuration audit, provider reimbursement, payment integrity, or healthcare data analysis
• Experience with Health Edge Source and/or Health Rules Payer systems
• Working knowledge of healthcare claims processing, including claim adjudication concepts, provider contract concepts, and common claim resolution practices
• Ability to read and interpret provider contract language, fee schedules, payment terms, and reimbursement methodologies and assess whether claims are processing as expected
• 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, or other contractual arrangements
• Understanding of physician/professional, ancillary, behavioral health, long-term care, or other non-facility reimbursement and billing principles
• Experience analyzing data, identifying trends, conducting root cause analysis, and preparing reports that support conclusions and recommendations
• Proficiency with Microsoft Office, especially Excel, including formulas, VLOOKUP or XLOOKUP, pivot tables, filtering, formatting, and data reconciliation; Word, PowerPoint, and Outlook
• Ability to communicate clearly, concisely, and professionally in written and verbal form with business and technical audiences
• Strong organizational, time-management, and prioritization skills, including the ability to manage multiple audits, analyses, 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 commute to 100 Church Street, NYC office every Tuesday, Wednesday & Thursday

Benefits

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