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
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