Sr. Consultant, Health & Medical Claim Auditor (US Remote)

About the position Discover a world of endless possibilities at Gallagher Benefit Services, where you'll have the power to shape the future of workplaces across industries. As a member of our team, you become the driving force behind positive change, helping clients build environments where employees thrive. Embrace the opportunity to impact lives, unlock potential, and create a legacy of remarkable transformation. A Sr. Consultant (Medical Claim Auditor) is expected to be a knowledgeable and reliable subject matter expert. The Medical Auditor is an integral part of the Medical Audit Team and is responsible for performing and supporting audits (medical, dental, vision, operational, Medicare, behavioral health, and pre/post-implementation, etc.) to validate that the coverage and payment of a claim are in compliance with the contractual, regulatory and custom plan guidelines. Sr. Consultants must show exemplary attention to detail, organizational skills, and an ability to manage time efficiently and handle changing or conflicting priorities. Sr. Consultants are positioned as project leaders on the delivery of internal initiatives and complex projects with responsibility for supporting growth through the following activities: Manage and perform retrospective and pre-implementation claim audits of healthcare plans such as medical, dental, vision and behavioral health. Review and understand all aspects of a client's benefit plan. Review and evaluate Administrative Services Agreement between the employer and Administrator. Evaluate the results of the initial claim data (Electronic Risk Assessment) and identify valid audit samples for review and response by the Administrator. Work with dedicated data analytics team to define and translate plan provisions for testing purposes ensuring that the scope of the audit is in line with the statement of work and client commitments. Travel to the Administrator to conduct the on-site claim audit as needed (Occasional travel is required to Administrator) Work collaboratively with Administrator to resolve exceptions, review supporting documentation and make final claim error determination. Ensure audit timeline is adhered to and deliver high level of service to Clients. Assist in supporting other auditors, Manager, Director, and Practice Leader as requested. Prepare and present detailed audit reports which clearly articulate the audit findings and recommendations to the Administrator and Client. Work collaboratively within the audit team as well as with internal and external customers. Participate in team meetings, conference calls, WebEx's etc. Interact directly with clients and respond to client requests, develop strong relationships with clients. Attain billable hours objective (apply acquired skills in client-productive ways).

Responsibilities

• Manage and perform retrospective and pre-implementation claim audits of healthcare plans such as medical, dental, vision and behavioral health.
• Review and understand all aspects of a client's benefit plan.
• Review and evaluate Administrative Services Agreement between the employer and Administrator.
• Evaluate the results of the initial claim data (Electronic Risk Assessment) and identify valid audit samples for review and response by the Administrator.
• Work with dedicated data analytics team to define and translate plan provisions for testing purposes ensuring that the scope of the audit is in line with the statement of work and client commitments.
• Travel to the Administrator to conduct the on-site claim audit as needed.
• Work collaboratively with Administrator to resolve exceptions, review supporting documentation and make final claim error determination.
• Ensure audit timeline is adhered to and deliver high level of service to Clients.
• Assist in supporting other auditors, Manager, Director, and Practice Leader as requested.
• Prepare and present detailed audit reports which clearly articulate the audit findings and recommendations to the Administrator and Client.
• Work collaboratively within the audit team as well as with internal and external customers.
• Participate in team meetings, conference calls, WebEx's etc.
• Interact directly with clients and respond to client requests, develop strong relationships with clients.
• Attain billable hours objective.

Requirements

• College degree (experience may be considered in waiving the degree requirement).
• 5+ years' experience in medical claims consulting, auditing, or other applicable medical claims industry experience.
• Must demonstrate a high level of medical claims or benefit administration knowledge - Medicare experience a plus.
• Proficient in the use of Microsoft Office suite of programs (Word, Excel, PowerPoint).
• Excellent oral and written communication skills required.
• Excellent organizational and time management skills.
• Personable communication style, positive outlook, and self-confidence.
• Ability to multi-task and acclimate to changing priorities witho

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