Role OverviewThis role is the safeguard behind trust in claims processing, catching configuration errors before they become member complaints, compliance gaps, or costly rework. The audits and root-cause fixes this person drives don't just clean up today's errors — they prevent tomorrow's. Get this right, and the whole claims operation runs smoother, faster, and more accurately, directly moving the needle on the outcomes clients and members actually feel.
What You Will Do
Lead configuration audits, translate plan language into system logic, validate configuration changes, analyze claims for accuracy, resolve configuration issues at the root, build test strategies, improve auto-adjudication rates, report on quality and risk, share findings that drive change, set the standard for audit quality, and support compliance and process initiatives.
Why It Might Be a Fit
The ideal candidate will have 3+ years of progressive experience in claims configuration, claims auditing, quality assurance, benefits administration, or related healthcare operations, and experience in self-funded health plans, third-party administration (TPA), healthcare payer operations, or managed care environments.
Requirements
- Bachelor's degree in Healthcare Administration, Business, Information Systems, or a related field, or an equivalent combination of education and experience
- 3+ years of progressive experience in claims configuration, claims auditing, quality assurance, benefits administration, or related healthcare operations
- Experience in self-funded health plans, third-party administration (TPA), healthcare payer operations, or managed care environments preferred
- Advanced experience working within the Javelina claims processing platform or similar core claims administration systems
- Experience interpreting Summary Plan Descriptions (SPDs), provider contracts, and benefit plan designs
- Demonstrated experience performing complex claims analysis, system testing, auditing, and root cause investigation
Benefits
- Competitive base salary
- Comprehensive medical and dental through our own health solutions
- Paid Time Off
- Mental health support
- Retirement planning
- Financial protection
- Professional development
- Learning budgets
- Mission-driven culture
- Paid holidays
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