Medical Claim Lead Auditor (Remote)

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 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 (e.g., 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

Qualifications

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.

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