Medical Claim Lead Auditor (Remote)

Lead Claims Auditor

As a Lead Claims Auditor, you will lead and perform medical claims audits on behalf of self-insured employer health plans. You will oversee day-to-day audit execution, ensure consistent and accurate issue documentation, partner with the claims administrator and internal stakeholders to resolve findings, and deliver clear, actionable reportingincluding draft and final audit reports and, when requested, client presentations.

Key Responsibilities:

• Perform audits of medical claims to confirm correct processing, including eligibility, accumulators, benefit application, professional and facility pricing, coordination of benefits, and payment accuracy.
• Interpret client plan documents and communicate key provisions, exclusions, and known risk areas to the team prior to and during the engagement.
• Coordinate daily audit workflow by assigning and rebalancing claim/work queues to support on-time, high-quality project completion.
• Serve as a primary point of contact for the administrator/vendor and internal audit stakeholders; communicate professionally, set expectations, and drive timely issue follow-up.
• Review and coach on error write-ups and supporting documentation to ensure findings are accurate, complete, and aligned to plan terms and audit standards.
• Manage post-audit activities by tracking open items, responding to questions, and supporting resolution of findings with the administrator in an accurate and timely manner.
• Prepare value-added draft and final audit reports that clearly summarize methodology, findings, root causes, and recommended corrective actions.
• Develop and maintain strong working relationships with vendor counterparts; understand their operating environment and incorporate that context into day-to-day audit work.
• Partner with fellow auditors to standardize approaches, share best practices, and provide day-to-day guidance to support consistent, high-quality results.
• Conduct pre-implementation and coverage-specific audits and ensure all audit workpapers and findings are documented and retained in accordance with project standards.
• This is a remote position open to candidates anywhere in the United States.

Qualifications

Required Qualifications:

• 5+ years of experience in health claims adjudication and/or medical claims auditing (major claims administrator, or consulting, health plan environment preferred).
• Demonstrated experience auditing both professional and facility claim types end to end, including benefits and pricing accuracy.
• Strong knowledge of self-insured health and welfare plan design and end-to-end claims administration, including vendor processes and operating environment.
• Familiarity with common plan types, including consumer-driven plans, PPO, indemnity, and managed care.
• Broad claims administration knowledge across medical (and ideally dental/behavioral health), including coordination of benefits and accumulator logic.
• Ability to lead work, provide coaching and quality review, and drive timely completion across multiple priorities.
• Excellent written and verbal communication skills, including the ability to translate complex claim issues into clear, client-ready findings.
• Working knowledge of ICD-10 and CPT codes and standard coding guidelines.
• High attention to detail, sound judgement, and a consistent commitment to quality and confidentiality.
• Collaborative, self-directed work style with the ability to operate effectively in a remote environment.
• Prior internal audit experience at a carrier and/or third-party external audit experience.
• Bachelor's degree preferred; high school diploma or equivalent required.

Preferred Qualifications

• Prior internal audit experience at a carrier and/or third-party external audit experience.
• Bachelor's degree preferred; high school diploma or equivalent required.

Compensation and Benefits

Base salary range and benefits information for this position are being included in accordance with requirements of various state/local pay transparency legislation. Please note that base salaries may vary for different individuals in the same role based on several factors, including but not limited to location of the role, individual competencies, education/professional certifications, qualifications/experience, performance in the role and potential for revenue generation.

Compensation

The base salary compensation range being offered for this role is $90,000 to $98,000 USD per year.

This role is also eligible for an annual short-term incentive bonus.

Company Benefits

WTW provides a competitive benefit package which includes the following (eligibility requirements apply):

• Health and Welfare: Mental health/emotional wellbeing (including Employee Assistance Program), medical (including prescription drug coverage and fertility benefits), dental, vision, Health Savings Account, Commuter Accounts, Health Care and Dependent Care Flexible Spending Accounts, company-paid life insurance, supplemental life insurance, AD&D, group accident, group critical illness, group legal, identity theft protection, wellbeing program, adoption assistance, surrogacy assistance, auto/home insurance, pet insurance, and other work/life resources.
• Leave Benefits: Paid Holidays, Annual Paid Time Off (includes paid state/local paid leave where required), Short-Term Disability, Long-Term Disability, Other Leaves (e.g., Bereavement, FMLA, ADA, Jury Duty, Military Leave, and Parental and Adoption Leave), Paid Time Off
• Retirement Benefits: Contributory Pension Plan and Savings Plan (401k). All Level 38 and more senior roles may also be eligible for non-qualified Deferred Compensation and Deferred Savings Plans.

Pursuant to the San Francisco Fair Chance Ordinance and Los Angeles County Fair Chance Ordinance for Employers, we will consider for employment qualified applicants with arrest and conviction records.

Note that visa employment-based non-immigrant visa sponsorship and/or assistance is not offered for this specific job opportunity.

This position will remain posted for a minimum of three business days from the date posted or until sufficient/appropriate candidate slate has been identified.

EOE, including disability/vets