Senior Claims Configuration & Quality Auditor

Personify Health; Northern (KY); Hybrid; USD 70,000 - 83,000; Full time

Benefits offered by this job

Base salary & full benefits

Medical and dental

Paid time off

Mental health support

Retirement planning

Professional development

Diversity & inclusion

Job summary

Personify Health is seeking a Senior Configuration Quality Audit Analyst to oversee end-to-end audits of complex claims configurations, ensuring accuracy against client requirements, contracts, and regulatory guidelines.

You will translate SPDs and contracts into precise system rules, validate changes before go-live, and analyze claims for correct adjudication. The role emphasizes root-cause fixes, test strategy development, and cross-functional collaboration to improve automated processing.

Qualifications

• Bachelor's degree in Healthcare Administration, Business, Information Systems, or related field.
• 3+ years of experience in claims configuration, auditing, quality assurance, or benefits administration.
• Experience in self-funded health plans, TPA, healthcare payer operations, or managed care environments preferred.

Responsibilities

• Lead end-to-end audits of complex claims configurations against client requirements, contracts, benefit plans, fee schedules, and regulatory guidelines.
• Translate SPDs, client requirements, and contracts into precise system rules, benefit matrices, and cost-sharing structures.
• Validate configuration changes before go-live, reviewing enrollment, contracts, plan design, and processing guidelines.
• Analyze complex claims to verify configuration, adjudication logic, and processing outcomes.
• Research root causes of issues and recommend durable fixes that stick.
• Develop test strategies and audit methodologies to support enhancements and updates.
• Improve auto-adjudication rates by evaluating configuration solutions.
• Prepare audit results and quality metrics for leadership decision making.
• Share findings to drive changes with internal stakeholders and leadership.
• Mentor peers and help set audit standards and best practices.

Skills

Claims configuration

Claims auditing

Quality assurance

Benefits administration

Healthcare operations

Education

Bachelor's degree in Healthcare Administration, Business, Information Systems

Tools

Javelina claims processing platform

SPD interpretation

Job description

Personify Health is seeking a Senior Configuration Quality Audit Analyst to oversee end-to-end audits of complex claims configurations, ensuring accuracy against client requirements, contracts, and regulatory guidelines.

You will translate SPDs and contracts into precise system rules, validate changes before go-live, and analyze claims for correct adjudication. The role emphasizes root-cause fixes, test strategy development, and cross-functional collaboration to improve automated processing.