Lead Specialist - US Medical Claim Audit

Company: Mercer

Description:

We are seeking a talented individual to join our Health Operations team at Mercer.

This role will be based in Noida. It is a hybrid role that has a requirement of working at least three days a week in the office.

Lead Specialist / Manager - US Health & Benefits Claims Audit

What can you expect?

We are seeking an experienced medical Claims Auditor to join our Medical Claims team in the Specialty practice of our US Health business.

The ideal candidate will be responsible for auditing medical claims from health insurance carrier claims files, interpreting carrier contracts and policies, and engaging with carrier audit teams to resolve discrepancies and ensure proper handling of claims.

As an employee of Mercer, the ideal candidate will adhere to company policies and performance standards and perform job duties as stipulated. This individual will contribute to the team s achievement of Service Level Agreements (SLAs) and Key Performance Indicators (KPIs).

This is an Individual Contributor role

We will count on you to:

• Ensure client-specific medical carrier claim files are processed meticulously and all aberrations identified
• Review plan benefit details (i.e., SPD, SMM, carrier plan materials, ASO agreement) for each audit, noting unique provisions/potential issues prior to audit review
• Analyze claims data using analytical tools, including audit software and Excel, and identify billing patterns and trends
• Interpret coding and results of system-processed medical claims
• Interpret and apply pertinent sections of carrier contracts and carrier policies to ensure proper claims handling
• Request supporting documentation and elicit carriers response to identified issues when necessary
• Address audit findings and any identified inconsistencies with the carriers audit team
• Evaluate carriers response(s) and processing policies and provide a rebuttal when necessary
• Escalate any challenges and/or concerns related to audit for immediate assistance and resolution to the lead audit consultant, as applicable
• Complete in-depth audit/review of selected sample claims (i.e., adherence to employee benefit design, rates, member(s) and plans financial responsibility, billing/payment and NCCI edits, etc.)
• Document findings accurately on designated work papers and/or audit software
• Complete all audit assignments within the stipulated time frame
• Maintain up-to-date knowledge of best practices related to health benefit claims and industry regulations

Note: Applicants should be flexible working in shifts

What you need to have?

• Graduate with minimum 5-8 years experience overall
• A strong understanding of how healthcare works in the United States
• Experience interacting with carriers (vendors) and their claims processes and policies
• Critical thinking, particularly when interpreting contracts and policies
• Discretionary judgement in assessing grey-area situations and escalating issues effectively
• A strong sense of accountability
• A solution-oriented mindset
• Intermediate to advanced level knowledge in MS Excel (Must)
• Strong oral & written communication skills
• Capability to pivot from audit to audit and adapt to multiple processing systems
• Ability to work during carrier-defined system availability

What makes you stand out?

• Deep knowledge of medical claims specifically in the United States
• Demonstrating an inherent preference for acting in a meticulous and diligent manner
• Communication that is structured, crisp and clear
• Exceptional judgement and clear rationales in decision-making
• Ability to prioritize time effectively across competing priorities
• Adaptable communicator, facilitator and problem solver
• High attention to detail
• Good relationship skills, Proven ability to work on own initiative as well as in a team

Why join our team:

• We help you be your best through professional development opportunities, interesting work and supportive leaders.
• We foster a vibrant and inclusive culture where you can work with talented colleagues to create new solutions and have impact for colleagues, clients and communities.
• Our scale enables us to provide a range of career opportunities, as well as benefits and rewards to enhance your well-being.

Marsh McLennan (NYSE: MMC) is a global leader in risk, strategy and people, advising clients in 130 countries across four businesses: Marsh , Guy Carpenter , Mercer and Oliver Wyman . With annual revenue of $23 billion and more than 85,000 colleagues, Marsh McLennan helps build the confidence to thrive through the power of perspective. For more information, visit marshmclennan.com , or follow on LinkedIn and X .

Marsh McLennan is committed to embracing a diverse, inclusive and flexible work environment. We aim to attract and retain the best people and embrace diversity of age, background, caste, disability, ethnic origin, family duties, gender orientation or expression, gender reassignment, marital status, nationality, parental status, personal or social status, political affiliation, race, religion and beliefs, sex/gender, sexual orientation or expression, skin color, or any other characteristic protected by applicable law.

Marsh McLennan is committed to hybrid work, which includes the flexibility of working remotely and the collaboration, connections and professional development benefits of working together in the office. All Marsh McLennan colleagues are expected to be in their local office or working onsite with clients at least three days per week. Office-based teams will identify at least one anchor day per week on which their full team will be together in person.

Mercer, a business of Marsh McLennan (NYSE: MMC), is a global leader in helping clients realize their investment objectives, shape the future of work and enhance health and retirement outcomes for their people. Marsh McLennan is a global leader in risk, strategy and people, advising clients in 130 countries across four businesses: Marsh, Guy Carpenter, Mercer and Oliver Wyman. With annual revenue of $23 billion and more than 85,000 colleagues, Marsh McLennan helps build the confidence to thrive through the power of perspective. For more information, visit mercer.com, or follow on LinkedIn and X.

Marsh McLennan is committed to embracing a diverse, inclusive and flexible work environment. We aim to attract and retain the best people and embrace diversity of age, background, caste, disability, ethnic origin, family duties, gender orientation or expression, gender reassignment, marital status, nationality, parental status, personal or social status, political affiliation, race, religion and beliefs, sex/gender, sexual orientation or expression, skin color, or any other characteristic protected by applicable law.

Marsh McLennan is committed to hybrid work, which includes the flexibility of working remotely and the collaboration, connections and professional development benefits of working together in the office. All Marsh McLennan colleagues are expected to be in their local office or working onsite with clients at least three days per week. Office-based teams will identify at least one anchor day per week on which their full team will be together in person.