Configuration and Quality Audit Manager | Hybrid NY

The Configuration & Quality Audit Manager will help build, lead and mature the new claim configuration auditing function responsible for validating accurate, complete, and compliant provider reimbursement across claims system configuration and adjudication outcomes. This role establishes the audit strategy, risk-based audit plan, testing and analytics methodology, reporting standards, and remediation governance for claim configuration and payment validation activities. The Manager serves as a reimbursement and configuration audit subject matter expert, leads analysts, partners with operational and technical stakeholders, and reports audit results, root causes, financial impact, and corrective action status to leadership.

Duties and Responsibilities

• 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.

Minimum Qualifications

• 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.

Preferred Qualifications

• Experience building, leading, or significantly improving an audit, quality assurance, payment integrity, claims configuration, or operational controls function.

• Experience using or overseeing SQL or data analytic/reporting tools such as SAS, ACL, Alteryx, Tableau, Power BI, Access, or equivalent tools.

• Experience developing dashboards, standardized reporting processes, data models, KPIs, or scorecards to support operational insights and executive reporting.

• Experience supporting internal audits, external audits, regulatory reviews, compliance reviews, or corrective action plan governance.

• Relevant healthcare, coding, auditing, data analytics, project management, Lean/Six Sigma, or leadership certification is a plus.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.  HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services,  LLC.

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All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

• All Other Locations (within approved locations): $88,700 - $131,920

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.