Auditor

• Audit and authorize reimbursement of specific medical stop loss claims
• Effectively mitigate client medical stop loss claims and provide excellent customer service
• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier
• Recognize cost mitigation opportunities
• Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits
• Initiate claims investigations and vendor referrals
• Interpret plan language and identify experimental services and subrogation opportunities
• Identify need for follow-up on pended claims and resolution
• Communicate effectively with carriers, vendors, and management
• Provide full claims service to both phone and written inquiries
• Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history
• Develop new and review old stop loss claim forms
• Assist with internal auditing of claims auditors and training of claims auditors

Senior Auditor, Stoploss Claim

• Independently and objectively helps plan and execute audits in accordance with professional auditing standards
• Performs or supports audits focused primarily on operational controls, asset safeguarding, and compliance with procedures, laws, and regulations
• Functions as in-charge auditor of the most complex audit reviews and/or cost reports
• May conduct reviews of account reconciliations performed by various financial areas
• Identifies and analyzes related key processes, systems, and controls to determine effectiveness
• Communicates audit status and results to management, with emphasis on discussing deficiencies and recommending corrective actions
• Prepares formal written work papers and reports, documenting audit work performed and expressing conclusion
• Assesses desk reviews performed by subordinate auditors to ensure that quality audit work is performed and on-the-job training is provided as necessary
• Assists in ensuring that all assigned audits are completed and reviewed in accordance with Generally Accepted Accounting Principles, Generally Accepted Auditing Standards and, Government Auditing Standards
• Coordinates the completion of these assignments in a manner which results in timely completion of all assignments in accordance with budget performance requirements as well as departmental interim goals
• Directs the day-to-day efforts of assigned audit staff by reviewing and planning assignments, training, and providing leadership and guidance
• Assists in the development and revision of work instructions, forms, and procedures
• Broadens and maintains working knowledge of applicable laws, regulations, and procedures through self-study programs, on-the-job training, attending seminars and network association’s formal training programs
• Communicates with internal and external areas as necessary to ensure efficient completion of assigned tasks

Lead Auditor, Medicare

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Senior Auditor, Stoploss Claim

Lead Auditor, Medicare

Senior Auditor, Stoploss Claim