Plan Build Auditor
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Job Description
Plan Build Auditor validating HealthEZ healthcare benefit configurations, claims adjudication, and implementation readiness. Auditing plan builds, testing outcomes, and improving configuration quality remotely.
Responsibilities:
- Review and validate new and modified benefit plan configurations against approved requirements, plan documents, and configuration standards
- Validate system configuration outcomes through structured testing and claim adjudication review
- Review benefit structures, coverage limitations, accumulators, cost-share arrangements, provider network configurations, pricing methodologies, denial logic, exception codes, member responsibility indicators, remit messaging, and claim processing outcomes
- Document audit findings, communicate recommendations, and track resolution activities through completion
- Perform follow-up reviews to validate corrective actions
- Analyze audit findings and recommend improvements to configuration quality and consistency
- Maintain audit documentation and support quality, accuracy, and implementation-readiness reporting
- Configure and maintain benefit plans according to approved requirements and business specifications
- Interpret plan documents and translate business requirements into system configuration
- Support implementations for new and existing clients, benefit changes, and system enhancements
- Participate in testing for configuration changes, system upgrades, regulatory updates, and operational initiatives
- Serve as a resource for complex configuration scenarios and adjudication-related questions
- Collaborate with cross-functional teams on implementation and operational performance
- Promote configuration standards, procedures, and departmental best practices
- Identify opportunities to strengthen quality controls and reduce configuration-related defects
- Conduct ongoing trend analysis of audit findings and quality results
- Provide feedback and recommendations to address recurring issues and improve configuration accuracy
- Update audit procedures, testing standards, configuration guidelines, and related documentation
- Partner with leadership and team members to improve operational efficiency, consistency, and quality outcomes
- Participate in departmental initiatives and special projects
Requirements:
- Minimum of five years of experience in health plan configuration, claims administration, benefit plan operations, or a related healthcare environment
- At least 1 year of VBA software knowledge; 2 years preferred
- Demonstrated knowledge of benefit plan design, claims adjudication, and configuration methodology
- Experience interpreting plan documents and translating requirements into system configuration
- Strong understanding of accumulators, limitations, exclusions, cost-share structures, and claim processing logic
- Experience performing testing, validation, or quality review activities within a plan configuration environment
- Strong analytical, problem-solving, and organizational skills
- Excellent attention to detail and commitment to accuracy
- Effective written and verbal communication skills
- Proficiency with Microsoft Excel and other business reporting tools
- Associate's or Bachelor's degree in Business, Healthcare Administration, Information Systems, or a related field preferred
- Experience auditing benefit plan configurations or implementation deliverables preferred
- Experience within a health plan, third-party administrator (TPA), or healthcare payer environment preferred
- Knowledge of exception codes, claim messaging, and adjudication-related configuration preferred
- Experience supporting implementation projects and system enhancement initiatives preferred
Benefits:
- Health benefits
- Retirement plan (401k)
- Paid time off
- Paid leave, including parental leave
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