Manager, Benefit Configuration Quality and Audit

Position Location: 100% remote

About the role

The Manager, Benefit Configuration Quality and Audit is responsible for leading a team of Plan Build Auditors who validate US healthcare plan build configurations against approved plan documents, benefit matrices, configuration requirements, coding standards, and implementation guidelines. This role requires strong US healthcare domain expertise, hands-on experience reading and interpreting lengthy plan documents, and deep understanding of benefit configuration, accumulator processing, eligibility and member data, claims adjudication logic, and ETL/data validation. The leader will drive audit consistency, configuration accuracy, defect prevention, data quality, quality metrics, team performance, stakeholder communication, and continuous improvement across the Plan Build QA audit function. This role manages 7 offshore Plan Build Audit contractors and serves as the primary face of audit quality governance for the plan build function within the Enterprise Quality Assurance organization.

Responsibilities

• Lead, coach, and manage a team of Plan Build Auditors responsible for auditing medical, dental, and vision plan configuration for new groups, renewals, conversions, and benefit changes
• Manage 7+ offshore contractors - including work allocation, communication cadence, productivity tracking, training support, and quality review across distributed teams
• Establish consistent, repeatable, and auditable quality review processes for plan build configuration across all audit team members
• Oversee audit workflows from preparation through defect documentation, retesting, closure, and final audit disposition
• Monitor audit quality, defect trends, aging items, reopened defects, QA rejection rates, and recurring configuration errors across the team
• Develop training materials, onboarding plans, calibration sessions, and knowledge-sharing routines to improve auditor consistency and domain expertise
• Review and validate audit coverage across plan-level fields, benefit-level configuration, accumulators, deductible and out-of-pocket logic, copay, coinsurance, network tiers, exclusions, authorizations, limitations, COB, and QPA methodology
• Ensure auditors validate configuration against approved source documents including plan documents, benefit matrices, mapping legends, best practice sheets, coding direction, validation guidance, vendor sheets, fact sheets, and division tables
• Demonstrate strong ability to read, interpret, and summarize lengthy healthcare plan documents, benefit booklets, SPDs, SBCs, amendments, and client-specific benefit requirements to identify configuration impacts, gaps, exclusions, limitations, and testing scenarios
• Define audit standards, checklists, quality metrics, reporting cadence, escalation paths, and governance routines to ensure consistency and accountability
• Lead root cause analysis for configuration defects and drive corrective and preventive actions to improve first-pass quality
• Build repeatable audit processes, training materials, checklists, dashboards, and governance routines to improve consistency, accountability, and quality outcomes
• Support claims testing validation by ensuring configuration logic aligns with expected adjudication outcomes including deductible, OOP, coinsurance, accumulator, authorization, maximum, and benefit logic
• Ensure audit validation includes eligibility, member data, accumulator inbound/outbound processing, claims data flows, and file-based data exchange impacts where applicable
• Partner with Plan Build, Business Operations, Product, and vendor teams to resolve questions, clarify requirements, and prevent downstream production issues
• Prepare executive-ready quality reporting including audit progress, risks, defect themes, SLA adherence, quality trends, and recommendations
• Build dashboards, audit trackers, defect trend reporting, SLA metrics, and leadership scorecards for visibility and governance

Requirements

• Bachelor's degree in healthcare administration, Business Administration, Information Systems, Computer Science, Quality Assurance, or a related field required; equivalent healthcare payer, TPA, plan build, configuration, audit, or QA leadership experience may be considered
• 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 managing offshore resources, including work allocation, communication cadence, productivity tracking, training support, and quality review across distributed teams, is preferred
• Experience reading, interpreting, and translating complex healthcare plan documents, SPDs, SBCs, amendments, and benefit summaries into audit criteria, configuration validation points, and testing scenarios
• Experience with healthcare platforms, SQL/data validation, defect management, audit documentation, root cause analysis, process improvement, and executive-level reporting preferred

Preferred 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 related areas are a plus

Skills

• 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
• Excellent written and verbal communication skills with the ability to present risks, quality trends, and recommendations to business, technical, vendor, and leadership stakeholders
• 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

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start/10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives