Medical Claim Lead Auditor (Remote)

WTW•Irvine, CA

55d•Remote

About The Position

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. Role will be working remotely within the posted locations.

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
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
Excellent oral and written communications skills
Team player with strong work ethic
Self-directed; requiring very little supervision
High School Diploma required

Nice To Haves

Previous internal audit experience at a carrier or third-party external audit experience a plus
Bachelor's Degree preferred

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