Manager, Benefit Configuration Quality and Audit
$100,000–$120,000 year
RemoteUnited States
Job Summary
Lead a team of Plan Build Auditors validating US healthcare plan configurations against approved documents, matrices, and coding standards. Manage seven offshore contractors through work allocation, productivity tracking, and quality reviews while establishing repeatable audit processes and governance routines. Oversee workflows from preparation through defect closure, monitor quality metrics, and drive root cause analysis to prevent recurring configuration errors. Review complex plan documents, benefit booklets, and amendments to identify configuration gaps, exclusions, and testing scenarios. Partner with Plan Build, Business Operations, and vendor teams to resolve issues and ensure alignment with claims adjudication logic. Prepare executive-ready quality reports, dashboards, and leadership scorecards to track SLA adherence and defect trends.
Required Qualifications
- Bachelor's degree in healthcare administration, Business Administration, Information Systems, Computer Science, Quality Assurance, or a related field
- 10+ years of experience in US healthcare payer, TPA, benefits administration, plan build, benefit configuration, claims, eligibility, accumulator processing, data validation, or quality assurance functions
- 5+ years of experience leading, mentoring, or supervising QA, audit, implementation, configuration, plan build, or operations teams
- Hands-on experience leading and managing a team of 10+ Plan Build Builders and Auditors, including workload planning, quality oversight, performance coaching, audit calibration, and delivery accountability
- Experience reading, interpreting, and translating complex healthcare plan documents, SPDs, SBCs, amendments, and benefit summaries into audit criteria, configuration validation points, and testing scenarios
- Strong leadership, coaching, and team management skills with the ability to guide Plan Build Builders, Auditors, and distributed/offshore resources
- Excellent analytical and problem-solving skills with the ability to identify configuration gaps, defect trends, root causes, and process improvement opportunities
- Strong understanding of US healthcare benefit configuration claims adjudication logic, eligibility, accumulators, and plan document interpretation
- Ability to read, interpret, and translate complex plan documents, benefit summaries, SPDs, SBCs, amendments, and client-specific requirements into audit criteria and testing scenarios
- Strong SQL, data validation, reconciliation, and reporting skills to support healthcare configuration and quality audit activities
- Strong attention to detail, documentation discipline, prioritization, and follow-through in a fast-paced implementation and production support environment
- Ability to build repeatable audit processes, training materials, checklists, dashboards, and governance routines to improve consistency, accountability, and quality outcomes
Desired Qualifications
- Experience managing offshore resources, including work allocation, communication cadence, productivity tracking, training support, and quality review across distributed teams
- Experience with healthcare platforms and tools such as VBA, Facets, CPBRE, IMPACT, Mainframe, MITS, PEX, Teradata, Denodo, TOAD, SQL Plus or similar systems
- Experience supporting self-funded, TPA, payer, or benefits administration environments
- Experience building dashboards, audit trackers, defect trend reporting, SLA metrics, or leadership scorecards
- Experience creating SOPs, audit checklists, training materials, onboarding plans, calibration sessions, and process governance documentation
- Certifications in quality assurance, process improvement, healthcare operations, or are a plus
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