Medical Audit Field Auditor

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As a Medical Audit Field Auditor, you will apply your medical claims audit, project management and client management skills to lead self-insured client audits. You will serve as the team leader and primary interface with health plan 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.

• Understand self-insured client�s plan designs and apprise team of unique provisions/issues prior to the claims audit
  
• Audit claims using the administrators claims system to determine if claims were adjudicated in error
  
• Submit error inquiries and perform research on administrators� claim systems during the audits
  
• Adjust claim audit workloads across audit team as necessary to achieve successful completion of project
  
• Clearly communicate and professionally interact with administrator 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 administrators� 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 to field auditors
  
• Review field auditor inquiries and provide guidance and coaching to field auditors
  
• Conduct pre-implementation and coverage specific audits and accurately document and record all audit findings
  
• 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.
  

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• 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
  
• Claims processing knowledge/exposure to one or more administrator claim systems such as UNET, WGS, NASCO, ACAS, Proclaim, PowerMHS, Facets, ITS, Bluechip
  
• Familiarity with all plan types including consumer-driven, PPO, POS, Indemnity and Managed Care
  
• Must demonstrate a high level of professional and facility claims administration knowledge, including experience with medical, dental, mental health and Medicare
  
• Must have detailed knowledge of ICD-10 and CPT and revenue codes and coding protocols
  
• Excellent oral and written communications skills
  
• Team player with strong work ethic
  
• Self-directed; requiring very little supervision
  
• Previous audit experience at a carrier or third-party external audit experience a plus