Plan Build Auditor

This is a fully remote position, open to applicants in Minnesota.

📋 Description

• Assess and verify new and updated benefit plan configurations against approved requirements, plan documents, and configuration standards.

• Confirm system configuration results through structured testing and claim adjudication assessments.

• Examine benefit structures, coverage limits, accumulators, cost-sharing arrangements, provider network setups, pricing strategies, denial logic, exception codes, member responsibility indicators, remit messaging, and claim processing results.

• Record audit findings, communicate suggestions, and monitor resolution activities until completion.

• Conduct follow-up reviews to confirm corrective measures.

• Analyze audit results and recommend enhancements for configuration quality and consistency.

• Maintain audit documentation and support quality, accuracy, and implementation-readiness reporting.

• Configure and uphold benefit plans according to approved requirements and business specifications.

• Interpret plan documents and convert business requirements into system configurations.

• Assist with implementations for new and existing clients, benefit adjustments, and system improvements.

• Engage in testing for configuration updates, system upgrades, regulatory changes, and operational initiatives.

• Act as a resource for complex configuration scenarios and adjudication-related inquiries.

• Collaborate with cross-functional teams on implementation and operational performance.

• Advocate for configuration standards, procedures, and departmental best practices.

• Identify opportunities to enhance quality controls and minimize configuration-related defects.

• Conduct ongoing trend analysis of audit findings and quality outcomes.

• Provide feedback and suggestions to address recurring issues and enhance configuration accuracy.

• Update audit procedures, testing standards, configuration guidelines, and associated documentation.

• Partner with leadership and team members to boost operational efficiency, consistency, and quality outcomes.

• Participate in departmental initiatives and special projects.

⛳️ Requirements

• A minimum of five years of experience in health plan configuration, claims administration, benefit plan operations, or a related healthcare field.

• At least 1 year of experience with VBA software; 2 years is preferred.

• Proven knowledge of benefit plan design, claims adjudication, and configuration methodologies.

• Experience in interpreting plan documents and translating requirements into system configurations.

• Strong understanding of accumulators, limitations, exclusions, cost-sharing structures, and claim processing logic.

• Experience in conducting testing, validation, or quality review activities within a plan configuration context.

• Strong analytical, problem-solving, and organizational abilities.

• Exceptional attention to detail and commitment to accuracy.

• Effective written and verbal communication skills.

• Proficiency in Microsoft Excel and other business reporting tools.

• An Associate's or Bachelor's degree in Business, Healthcare Administration, Information Systems, or a related field is preferred.

• Preferred experience in auditing benefit plan configurations or implementation deliverables.

• Experience in a health plan, third-party administrator (TPA), or healthcare payer environment is preferred.

• Knowledge of exception codes, claim messaging, and adjudication-related configurations is preferred.

• Experience in supporting implementation projects and system enhancement initiatives is preferred.

🏝️ Benefits

• Health benefits.

• Retirement plan (401k).

• Paid time off.

• Paid leave, including parental leave.