Configuration and Quality Audit Manager | Hybrid NY

**Duties and Responsibilities**

+ Build, lead, and mature the claim configuration quality audit function, including audit planning, methodology, governance, quality standards, reporting, and remediation oversight.
+ Develop and maintain a risk-based audit plan that prioritizes claim configuration and reimbursement risks based on volume, dollar exposure, provider type, line of business, regulatory or contractual commitments, recent configuration activity, and known issue patterns.
+ Establish claim configuration audit programs, sampling logic, testing protocols, workpaper standards, quality review expectations, issue rating criteria, and documentation requirements.
+ Oversee routine, targeted, and risk-based audits and analyses of provider pricing configuration and claims across multiple lines of business, products, and provider types.
+ Ensure claim processing outcomes are validated against provider contract terms, fee schedules, reimbursement methodologies, benefi...