Medical Claim Lead Auditor (Remote)

As a Medical Claim Lead Auditor, you will apply your audit, project management and client management skills to lead client audits. You will serve as the team leader and primary interface with administrators. You will review discrepancy issues identified by field auditors, re-adjudicate claims, resolve open issues, and draft the final report. You will contribute to the creation of new tools and approaches.

The Responsibilities

• Conduct pre-implementation and coverage specific audits and accurately document and record all audit findings
• Understand client’s plans and apprise team of unique provisions/issues prior to audit
• Adjust workloads as necessary to achieve successful completion of project
• Clearly communicate and professionally interact with vendor and audit team
• Review documentation of potential discrepancies for thoroughness and accuracy
• Resolve post-audit activities in an accurate and timely fashion
• Write quality value-added draft report in a timely manner
• Participate in client presentation of findings, when requested
• Understand vendors’ processes, operating environment, and specific challenges and take them into account with daily work
• Develop working relationship with vendor counterparts
• Distribute individual claim/work queues to team in a timely manner
• Efficiently utilize audit-specific analytic techniques, tools and processes
• Ensure that Professional Excellence protocols are followed
• Meet billable hours target
• Seek opportunities to improve work processes and methods in pursuit of quality output and service delivery
• Role will be working remotely within the posted locations.

Qualifications

• 5+ years’ experience in health claims adjudication gained preferably in a consulting environment and/or in a major insurance claims administrator or health plan environment
• Solid understanding of health and welfare plan design and all areas of claims administration, as well as of vendors’ processes and operating environment
• Familiarity with all plan types including consumer-driven, PPO, Indemnity and Managed Care
• Must demonstrate a high level of claims administration knowledge, including experience with medical, dental, mental health and Medicare
• Detailed knowledge of ICD-10 and CPT codes and coding protocols
• Must have prior experience in medical claim auditing (., re-evaluating medical claims that were previously processed for adherence to plan design and other program parameters).
• Experience auditing both professional and facility claims types.
• Must have experience auditing both benefits and pricing.
• Excellent oral and written communications skills
• Team player with strong work ethic
• Self-directed; requiring very little supervision
• Previous internal audit experience at a carrier or third-party external audit experience a plus
• Bachelor's Degree preferred; High School Diploma required