Internal Auditor

Mercy Health System Corporation•Janesville, WI

1d•Onsite

About The Position

Conduct comprehensive claims audits to ensure compliance with fee schedules, benefit plans, contractual obligations, service-level agreements, and claim turnaround standards. Evaluate claims processing activities for adherence to industry best practices, federal and state regulatory requirements, organizational policies and procedures, provider contracts, and applicable accreditation standards. Analyze audit results, identify trends and areas of risk, and prepare detailed written reports summarizing findings, root causes, and recommendations for corrective action and process improvement. Collaborate with internal stakeholders to monitor compliance, improve operational effectiveness, and support regulatory readiness. MercyCare administers a diverse portfolio of health insurance products, including Medicaid, Exchange, ERISA, and commercial plans, and operates within regulatory frameworks established by the Wisconsin Office of the Commissioner of Insurance (OCI), Illinois Department of Insurance (DOI), and other applicable federal and state agencies. The role requires a strong understanding of health plan operations, claims administration, and regulatory compliance across multiple lines of business.

Requirements

Minimum 2 years audit experience in health care industry.
Effective written and oral communication skills.
Excellent analytical/interpretive skills.
High degree of accuracy.
Proficiency in application of computers and software programs such as Excel.

Nice To Haves

Bachelor's degree in accounting or business administration preferred with concentration in health care also preferred.
Certified Internal Auditor (CIA) certification
Certified Healthcare Auditor (CHA)
Certified Public Accountant (CPA)
Registered Health Information Administrator (RHIA)

Responsibilities

Conduct audit interviews with front line staff in all functional areas that fall under claim operations.
Test, create flow charts and map operational processes that touch the outcome of claims accuracy.
Perform routine and moderately complex audits on claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration.
Research claim processing issues and errors to determine their origin and appropriate resolution.
Interacts with Operations management regarding trends in order to improve claims processing accuracy and incorporate into training programs, policies and procedures.
Create audit reports to document audit findings, which will result in audit recommendations, reports and claims audit criteria enhancements.
Perform special project audits and reviews as requested by other departments.