Plan Build Auditor

The Opportunity The Plan Build Auditor is responsible for the review, validation, and quality oversight of benefit plan configurations to ensure accuracy, consistency, and alignment with approved business requirements and plan documentation. This role serves as a subject matter expert in plan configuration and claims adjudication, providing an independent assessment of configuration quality prior to implementation.

Working closely with Plan Builders, Operations, and Leadership, the Plan Build Auditor evaluates configuration outcomes, identifies discrepancies, validates corrective actions, and supports the ongoing enhancement of quality standards and configuration practices. The role also serves as an experienced plan configuration resource and may participate in complex build activities, implementation initiatives, and departmental projects as needed. This is a position that can be supported 100% remotely.

What you'll doPlan Build Audit & Validation Conduct detailed reviews of new and modified plan configurations to ensure alignment with approved requirements, plan documents, and established configuration standards.

Validate system configuration outcomes through structured testing and claim adjudication review.

Review benefit structures, coverage limitations, accumulators, cost-share arrangements, provider network configurations, pricing methodologies, and related setup components.

Evaluate denial logic, exception code configuration, member responsibility indicators, remit messaging, and claim processing outcomes for accuracy and consistency.

Document audit findings, communicate recommendations, and track resolution activities through completion.

Perform follow-up reviews to validate corrective actions and ensure identified issues have been fully resolved.

Analyze trends in audit findings and recommend opportunities to improve configuration quality and consistency.

Maintain audit documentation and support reporting related to quality, accuracy, and implementation readiness.

Configuration & Implementation Support Configure and maintain benefit plans in accordance with approved requirements and business specifications.

Interpret plan documents and translate business requirements into system configuration.

Support implementation activities for new and existing clients, benefit changes, and system enhancements.

Participate in testing efforts related to configuration changes, system upgrades, regulatory updates, and operational initiatives and projects.

Serve as a resource for complex configuration scenarios and adjudication-related questions.

Collaborate with cross-functional teams to support successful implementation and ongoing operational performance.

Quality & Process Improvement Promote adherence to configuration standards, established procedures, and departmental best practices.

Identify opportunities to strengthen quality controls and reduce configuration-related defects.

Conduct ongoing trend analysis of audit findings and quality results

Provide timely, actionable feedback and recommendations to address recurring issues, strengthen controls, and improve configuration accuracy

Update audit procedures, testing standards, configuration guidelines, and related documentation to reflect approved process changes and lessons learned.

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

Participate in departmental initiatives and special projects as assigned.

What we expect from you Minimum of five years of experience in health plan configuration, claims administration, benefit plan operations, or a related healthcare environment.
1 year of VBA Software knowledge.

Demonstrated knowledge of benefit plan design, claims adjudication, and configuration methodology.

Experience interpreting plan documents and translating requirements into system configuration.

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

Experience performing testing, validation, or quality review activities within a plan configuration environment.

Strong analytical, problem-solving, and organizational skills.

Excellent attention to detail and commitment to accuracy.

Effective written and verbal communication skills.

Proficiency with Microsoft Excel and other business reporting tools.

Preferred2 years of VBA Software knowledge.

Experience auditing benefit plan configurations or implementation deliverables.

Experience with in a health plan, third-party administrator…