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.

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