Who We Are

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Ready to Ensure Precision in Every Claim Through Expert Auditing and Validation?

We're seeking a detail-oriented professional who can ensure accurate and timely auditing of critical information on claims databases. As our Claims Configuration Quality Assurance Analyst, you'll validate accuracy of configuration, translate complex plan descriptions into system rules, and ensure adherence to business and system requirements across contracting, benefits, prior authorizations, and fee schedules.

What makes this role different

✓ Configuration expertise: Translate complex Summary Plan Descriptions (SPD) and client-specific requirements into system rules, benefits matrices, and cost-sharing structures

✓ Quality assurance focus: Validate accuracy of new complex configuration processes and automated solutions ensuring proper claim adjudication

✓ Problem-solving impact: Research and troubleshoot complex claim adjudication issues while recommending solutions to improve auto-adjudication

✓ Cross-functional collaboration: Work with multiple stakeholders to evaluate accuracy of updates/changes across enrollment, contracts, and benefit plan designs

What You'll Actually Do

Translate complex requirements: Convert Summary Plan Descriptions (SPD) and client-specific requirements and cost share requirements into system rules, benefits matrices, and cost-sharing structures.

Validate configuration accuracy: Interpret and validate accuracy of new complex configuration processes and solutions while ensuring automated configuration processes function correctly.

Review system updates: Evaluate documentation regarding updates/changes to member enrollment, provider contracts, benefit plan designs, claim processing guidelines, and system configuration requirements.

Ensure processing accuracy: Assess accuracy of updates/changes as applied to appropriate modules within core claims processing system while reviewing configured services for correctness.

Interpret contract terms: Understand and validate contract term agreements for all different claim types and services billed under Institutional and non-institutional claims.

Communicate findings: Effectively communicate audit findings and outcomes to stakeholders while maintaining comprehensive documentation of validation results.

Develop testing scenarios: Create test case scenarios while recommending solutions to improve auto-adjudication and system performance.

Troubleshoot complex issues: Research and troubleshoot complex claim adjudication issues while identifying and resolving claim discrepancies using SPDs, provider contracts, and regulatory requirements.

Support quality standards: Assist manager in establishing peer review standards and methodology while writing complex ad-hoc reports as needed.

What You Bring to Our Mission

• The foundational experience:

  • Bachelor's degree or equivalent combination of education and experience
  • Strong understanding of Javelina claim processing system
  • Proficient in QA testing methodologies and root cause analysis of claims/system errors

  The technical expertise:

  • Strong ability to interpret and translate SPDs into system logic and rule sets
  • Knowledge of HIPAA, EDI transactions, and claim processing administration
  • Knowledge of CPT, HCPCS, CDT, and ICD-10 coding standards
  • Strong experience using Microsoft Office applications (Excel, Word, Outlook, PowerPoint, Teams)

  The analytical competencies:

  • Ability to identify and troubleshoot claim discrepancies by utilizing SPDs, provider contracts, regulatory requirements, and various claims-related resources
  • Strong attention to detail with ability to validate complex configuration processes and solutions
  • Capability to develop comprehensive test case scenarios and identify system improvement opportunities

  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

Why You'll Love It Here

We believe in total rewards that actually matter—not just competitive packages, but benefits that support how you want to live and work.

Your wellbeing comes first:

• Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
• Mental health support and wellness programs designed by experts who get it
• Flexible work arrangements that fit your life, not the other way around

Financial security that makes sense:

• Retirement planning support to help you build real wealth for the future
• Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
• Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage

Growth without limits:

• Professional development opportunities and clear career progression paths
• Mentorship from industry leaders who want to see you succeed
• Learning budget to invest in skills that matter to your future

A culture that energizes:

• People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
• One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
• We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
• Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable

The practical stuff:

• Competitive base salary that rewards your success
• Unlimited PTO policy because rest and recharge time is non-negotiable
• Benefits effective day one—because you shouldn’t have to wait to be taken care of

Ready to create a healthier world while building the career you want? We're ready for you.

No candidate will meet every single qualification listed. If your experience looks different but you think you can bring value to this role, we'd love to learn more about you.

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $22.00 to $28.00 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

#WeAreHiring #PersonifyHealth

Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to talent@personifyhealth.com. All of our legitimate openings can be found on the Personify Health Career Site.