Claims Configuration and Quality Audit Analyst | Hybrid NY

Duties and Responsibilities

• 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.

Minimum Qualifications

• 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.

Preferred Qualifications

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

• Experience in healthcare audit or quality assurance, including workpapers, testing scripts, sampling methodologies, issue logs, and remediation validation.

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

• Project coordination experience, including developing plans, establishing deadlines, monitoring milestones, escalating risks, and resolving dependencies.

• Relevant healthcare, coding, auditing, data analytics, or project management certification is a plus.

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620

All Other Locations (within approved locations): $61,300 - $91,120

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.