Lead Claims Audit Examiner

As a Lead Auditor you will apply your medical claims audit, project management and client management skills to lead self-insured client audits. You will serve as the team leader and primary interface with health plan 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

• Understand self-insured client’s plan designs and apprise team of unique provisions/issues prior to the claims audit
• Audit claims using the administrators claims system to determine if claims were adjudicated in error
• Submit error inquiries and perform research on administrators’ claim systems during the audits
• Adjust claim audit workloads across audit team as necessary to achieve successful completion of project
• Clearly communicate and professionally interact with administrator 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 administrators’ 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 to field auditors
• Review field auditor inquiries and provide guidance and coaching to field auditors
• Conduct pre-implementation and coverage specific audits and accurately document and record all audit findings
• 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
• This is a Remote opportunity

 The Requirements

• 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
• Claims processing knowledge/exposure to one or more administrator claim systems such as UNET, WGS, NASCO, ACAS, Proclaim, PowerMHS, Facets, ITS, Bluechip
• Familiarity with all plan types including consumer-driven, PPO, POS, Indemnity and Managed Care
• Must demonstrate a high level of professional and facility claims administration knowledge, including experience with medical, dental, mental health and Medicare
• Must have detailed knowledge of ICD-10 and CPT and revenue codes and coding protocols
• Excellent oral and written communications skills
• Team player with strong work ethic
• Self-directed; requiring very little supervision
• Previous audit experience at a carrier or third-party external audit experience a plus

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 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 (Producer roles only).

Compensation

The base salary compensation range being offered for this role is $80,000 – $90,000 USD.

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 Benefits: Medical (including prescription coverage), Dental, Vision, Health Savings Account, Commuter Account, Health Care and Dependent Care Flexible Spending Accounts, Group Accident, Group Critical Illness, Life Insurance, AD&D, Group Legal, Identify Theft Protection, Wellbeing Program and Work/Life Resources (including Employee Assistance Program)
• 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)
• 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. If Level 38 or more senior role is in Washington State, you must add the retirement benefits paragraph to the job description. Please note: Producer Sales roles are not currently eligible for the WTW Pension Plan.

EOE, including disability/vets