Manager, Medical Audit Services

Lockton • Minneapolis, MN

4h

About The Position

The Manager, Medical Audit Services is responsible for overseeing and executing complex medical plan audits across various lines of business including Commercial, Medicare, Medicaid, Exchange, DSNP, and EGWP. This role involves developing and maintaining internal reference documents and audit templates, leading training for new hires, and serving as a subject matter expert in claim payment and compliance. Key duties include utilizing claim data for sample selection, conducting on-site audits to verify claim accuracy, collaborating with carriers to identify root causes of errors, reporting findings to clients, and assisting consultants in client engagement. The manager is also tasked with developing tools for tracking audit status and performance indicators.

Requirements

• College degree (experience may be considered in lieu of college degree)
• 7+ years’ experience in medical claims auditing or consulting
• Must demonstrate a high level of medical claims and health benefit administration knowledge under various lines of business (Commercial, Medicare, Medicaid)
• Exceptional oral and written communication skills with high attention to detail
• Ability to deliver results per an agreed upon timeline while keeping all stakeholders informed
• Self-directed with strong project management skills
• Ability to adjust to changing priorities without losing momentum toward overarching goals
• Comfortable working collaboratively with others at all levels of an organization
• Strong people leader with the ability to identify others’ motivators and potential for growth
• Intermediate or expert level experience with Microsoft Suite (Word, Excel, PowerPoint)
• Ability to travel as required for audits

Nice To Haves

• Experience with SQL and/or Alteryx
• Advanced degree in healthcare analytics or similar field
• Experience in medical billing or coding

Responsibilities

• Responsible for internal reference documents for Consultants and Health & Welfare teams, leading training sessions to educate new hire colleagues on medical audit offerings
• Create and maintain audit templates such as audit notification letters, documentation request lists, report templates, sample workbooks, etc.
• Responsible for performing and supporting complex audits of medical plans including but not limited to retrospective claims, operational, pre & post-implementation audits across all lines of business (Commercial, Medicare, Medicaid, Exchange, DSNP, EGWP)
• Lead others in completing audits of medical plans
• Serve as a subject matter expert in claim payment and compliance relative to client contracts, regulatory requirements and vendor health programs
• Utilize results of initial claim data evaluations to select focused audit samples for review and response by the carrier; attend on-site audit to review claims and backup detail as necessary to determine accuracy of claim processing and payment
• Work with carriers to determine root cause of errors, determine impact, and report audit results to clients of varying size and type (employers, health plans, etc)
• Assist Consultants with discovery calls to explore potential clients’ interest in completing audits and developing solutions that meet their unique needs
• Develop a tool to track audit status and results, developing key performance indicators and audit statistics/insights
• Other responsibilities as deemed necessary to support the business

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 5,001-10,000 employees