Responsibilities Ready to make sure every claim gets it right?

Why This Role Matters

Every claim that runs through our system tells a real story — a member getting the care they need, a provider getting paid correctly, a client trusting that their plan is doing what it's supposed to do. This role is the safeguard behind that trust: catching configuration errors before they become member complaints, compliance gaps, or costly rework. When benefit plans, fee schedules, and adjudication rules are set up right, claims process faster, auto-adjudication rates climb, and clients stop worrying and start relying on us. 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'll Actually Do

• Lead configuration audits: Own the end-to-end audit and validation of complex claims system configurations, confirming accuracy against client requirements, provider contracts, benefit plans, fee schedules, and regulatory guidelines.
• Translate plan language into system logic: Interpret Summary Plan Descriptions (SPDs), client-specific requirements, and contractual agreements, converting them into precise system rules, benefit matrices, and cost-sharing structures.
• Validate configuration changes: Review updates to member enrollment, provider contracts, plan design, claims processing guidelines, and system enhancements before they go live.
• Analyze claims for accuracy: Dig into complex institutional and professional claims to verify configuration, adjudication logic, and processing outcomes are working as intended.
• Resolve configuration issues at the root: Research and troubleshoot claim adjudication and configuration problems, tracing them to root cause and recommending fixes that stick.
• Build test strategies: Develop test cases and audit methodologies that support system enhancements, configuration updates, and process improvements.
• Improve auto-adjudication rates: Evaluate automated configuration solutions and identify opportunities to boost accuracy, efficiency, and straight-through processing.
• Report on quality and risk: Prepare and maintain audit results, quality metrics, and ad hoc reports that give leadership what they need to make informed decisions.
• Share findings that drive change: Communicate audit findings, trends, risks, and recommendations to internal stakeholders and leadership in a way that leads to action.
• Set the standard for audit quality: Provide subject matter expertise and mentoring to peers, helping shape audit standards, quality controls, and best practices across the team.
• Support compliance and process initiatives: Participate in cross-functional efforts focused on compliance, operational excellence, and system optimization.
• Uphold regulatory and data standards: Ensure ongoing adherence to HIPAA, claim processing requirements, and data integrity controls.

What You Bring to Our Team

Education & Experience:

• 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

Technical Skills:

• 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

The professional qualities:

• Flexibility to meet changing business requirements with strong commitment to high-quality, on-time delivery
• Excellent communication skills for presenting audit findings to diverse stakeholders
• Problem-solving mindset with ability to recommend solutions that improve auto-adjudication efficiency
• Collaborative approach to working with cross-functional teams on system updates and configuration changes

Benefits

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $70,000-$83,000 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.