Claims Configuration and Quality Audit Analyst
Healthfirst
Claims Configuration and Quality Audit Analyst
Healthfirst
Non-profit insurer offering MLTC, Medicare Advantage.
Duties and Responsibilities
Perform routine, targeted, and risk-based audits of provider pricing configuration and claims across multiple lines of business, products, and provider types.
Interpret provider contract reimbursement language and translate terms into expected system outcomes for claims audit testing.
Validate claim processing outcomes against provider contract terms, fee schedules, reimbursement methodologies, benefit or business rules, and applicable federal and state requirements.
Review technical specifications, configuration documentation and reimbursement policy to confirm business requirements and provider contract provisions are accurately implemented.
Identify configuration defects, claim adjudication variances, underpayments, overpayments, quality gaps, and operational control failures.
Analyze claim, provider contract, and configuration data to detect outliers, trends, variances, and root causes.
Conduct financial and operational impact analyses for identified defects, including affected claim volume, dollars at risk, provider or member impact, lines of business, and remediation scope.
Use Excel and query tools to manage large data sets, standardize reports, prioritize audit targets, perform reconciliations, and summarize actionable findings.
Prepare recurring and ad hoc reports on audit results, defect trends, quality performance and remediation status.
Prepare clear audit workpapers, written findings, summaries, and recommendations that adequately support conclusions and remediation actions.
Work directly with business units and technical teams as a subject matter resource on claims configuration, provider reimbursement, claims processing, audit findings, and operational dependencies.
Validate remediation activities and retest as necessary to confirm sustainable resolution.
Support management decision-making by identifying trends, escalating barriers, and presenting concise analyses and recommendations.
Maintain knowledge of supported operational areas, risk landscape, financial impact drivers, processes, controls, and performance standards.
Perform other projects and duties as assigned.
Minimum Qualifications
Bachelor's degree from an accredited institution or equivalent combination of education and relevant work experience.
At least three years of experience in a managed care organization, commercial health plan, government program, third-party administrator, or other healthcare operations environment performing claims analysis, configuration audit, provider reimbursement, payment integrity, or healthcare data analysis.
Experience with Health Edge Source and/or Health Rules Payer systems.
Working knowledge of healthcare claims processing, including claim adjudication concepts, provider contract concepts, and common claim resolution practices.
Ability to read and interpret provider contract language, fee schedules, payment terms, and reimbursement methodologies and assess whether claims are processing as expected.
Knowledge of medical terminology and healthcare coding sets, including CPT, HCPCS, ICD-10, revenue codes, modifiers, place-of-service codes, and reimbursement groupers as applicable.
Experience with facility reimbursement methodologies such as DRG, APC, APG, per diem, percent of charge, case rate, bundled payment, carve-out, or other contractual arrangements.
Understanding of physician/professional, ancillary, behavioral health, long-term care, or other non-facility reimbursement and billing principles.
Experience analyzing data, identifying trends, conducting root cause analysis, and preparing reports that support conclusions and recommendations.
Proficiency with Microsoft Office, especially Excel, including formulas, VLOOKUP or XLOOKUP, pivot tables, filtering, formatting, and data reconciliation; Word, PowerPoint, and Outlook.
Ability to communicate clearly, concisely, and professionally in written and verbal form with business and technical audiences.
Strong organizational, time-management, and prioritization skills, including the ability to manage multiple audits, analyses, and deadlines.
Strong interpersonal skills and ability to establish effective working relationships across departments.
Ability and willingness to learn new technical, operational, and regulatory information.
Ability to commute to 100 Church Street, NYC office every Tuesday, Wednesday & Thursday.
Preferred Qualifications
Experience using SQL or data analytic/reporting tools such as Alteryx, Tableau, Power BI, Access, or equivalent tools.
Experience in healthcare audit or quality assurance, including workpapers, testing scripts, sampling methodologies, issue logs, and remediation validation.
Experience developing dashboards, standardized reporting processes, or data models to support operational insights.
Project coordination experience, including developing plans, establishing deadlines, monitoring milestones, escalating risks, and resolving dependencies.
Relevant healthcare, coding, auditing, data analytics, or project management certification is a plus.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLCshallnotdiscriminateagainstanydisabledemployeeorapplicantinregard to any position for which the employee or applicant is otherwise qualified.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.
All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Hiring Range*:
Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620
All Other Locations (within approved locations): $61,300 - $91,120
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
Non-profit insurer offering MLTC, Medicare Advantage.
Healthfirst is a nonprofit health insurer in the New York metropolitan area offering a range of health plans, including Managed Long-Term Care (MLTC) for people who need ongoing care, Medicare Advantage with extra benefits, and the Essential Plan for income-qualified individuals. MLTC coordinates in-home and community-based care; Medicare Advantage combines Medicare with additional benefits in a single plan; the Essential Plan provides affordable coverage through a low-cost option, all delivered through a network of healthcare providers funded by premiums and government support. It differentiates itself through its nonprofit status, strong local focus, and partnerships that connect New Yorkers to a coordinated set of public-program-aligned products alongside Medicare Advantage. Its goal is to expand access to affordable, comprehensive health coverage for New Yorkers, especially vulnerable groups, by leveraging its local presence and provider network.
Explore more opportunities at Healthfirst