Medical Plan Benefit Configuration Auditor

Job Description

Job Description

Medical Plan Benefit Configuration Auditor

Our client is looking for a meticulous and analytical Benefit Configuration Auditor contractor to join the Claims Quality Assurance team. In this role, you will be a vital safeguard, ensuring the company’s systems are configured flawlessly to match client benefit plans. You will protect plan assets, ensure compliance, and build trust by making sure every claim is paid right, every time.

What you’ll do:

• Drive Payment Integrity: Conduct comprehensive audits of the company’s system's benefit configuration against Summary Plan Descriptions (SPDs) and other plan documents to ensure perfect alignment and accurate claims processing.
• Ensure Coding and Regulatory Accuracy: Scrutinize medical claims for correct application of industry coding standards (ICD-10, CPT, HCPCs) and ensure the system configuration complies with all regulatory requirements, including ACA, ERISA, and other federal and state laws.
• Investigate and Analyze: Perform deep-dive, root cause analysis on high-volume claims data to identify trends, uncover configuration gaps, and pinpoint opportunities for improvement.
• Collaborate for Quality: Partner with internal teams, including Claims Operations, Configuration, Engineering, and Client Success, to test benefit rules, validate accumulator and provider contract setups, and communicate audit outcomes and remediation strategies clearly.
• Develop and Recommend Solutions: Translate your findings into actionable recommendations for the Benefits Configuration team. Help establish and document new standards, policies, and procedures to enhance operational excellence.
• Inform and Advise: Prepare and present clear, data-driven reports on audit findings, trends, and improvement initiatives for Leadership and other key stakeholders.

What you'll bring to the team:

• Deep Healthcare Claims Expertise: 3+ years of experience in medical claims processing and system configuration within a TPA or health insurance payer environment. You have a thorough understanding of adjudication workflows, payment policies, and compliance.
• Medical Coding Proficiency: A strong command of ICD-10, CPT, and HCPCs coding systems and their application in a payer setting. A solid understanding of medical terminology is essential. A Certified Professional Coder (CPC) or similar certification is highly preferred.
• An Analytical and Inquisitive Mindset: You excel at researching complex issues, analyzing data to find patterns, and thinking critically to solve problems. You're comfortable challenging the status quo to drive meaningful improvements.
• Exceptional Communication Skills: You can clearly and concisely articulate complex findings and recommendations to diverse audiences, from technical configuration teams to client-facing managers.
• A Meticulous Eye for Detail: You are highly organized and have an unwavering commitment to accuracy, even when managing competing priorities in a fast-paced environment.
• Comfort with Ambiguity: You thrive on creating clarity. You enjoy researching and developing consistent policies and are comfortable making well-reasoned decisions when clear answers aren't readily available.

Compensation: $30 - $42.50 per hour 

ID#: 2463