Job Description
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 ResponsibilitiesConduct pre-implementation and coverage specific audits and accurately document and record all audit findingsUnderstand client's plans and apprise team of unique provisions/issues prior to auditAdjust workloads as necessary to achieve successful completion of projectClearly communicate and professionally interact with vendor and audit teamReview documentation of potential discrepancies for thoroughness and accuracyResolve post-audit activities in an accurate and timely fashionWrite quality value-added draft report in a timely mannerParticipate in client presentation of findings, when requestedUnderstand vendors' processes, operating environment, and specific challenges and take them into account with daily workDevelop working relationship with vendor counterpartsDistribute individual claim/work queues to team in a timely mannerEfficiently utilize audit-specific analytic techniques, tools and processesEnsure that Professional Excellence protocols are followedMeet billable hours targetSeek opportunities to improve work processes and methods in pursuit of quality output and service deliveryRole will be working remotely within the posted locations.Qualifications 5years' experience in health claims adjudication gained preferably in a consulting environment and/or in a major insurance claims administrator or health plan environmentSolid understanding of health and welfare plan design and all areas of claims administration, as well as of vendors' processes and operating environmentFamiliarity with all plan types including consumer-driven, PPO, Indemnity and Managed CareMust demonstrate a high level of claims administration knowledge, including experience with medical, dental, mental health and MedicareDetailed knowledge of ICD-10 and CPT codes and coding protocolsExcellent oral and written communications skillsTeam player with strong work ethicSelf-directed; requiring very little supervisionPrevious internal audit experience at a carrier or third-party external audit experience a plusBachelor's Degree preferred; High School Diploma required.