GHRS Health Claims Audit, Sr. Assoc.

Job Description -- As a member of the GHRS Health & Welfare, National Medical Claims Review Practice of PricewaterhouseCoopers LLP, the candidate will be expected to provide a broad range of claims-related review services to clients regarding the administration health care benefits.
This individual will:
? Assist in the supervision of the claims review staff, since staff will work closely with this person when performing the on-site reviews
? Depending on experience level, play an active role in proposal writing and new business development
? Function as a key member of our National Claims Review practice
? Translate benefit plan language (SPD?s) into standard review program procedures
? Work with our major clients to conduct/manage random sample reviews to determine medical claims processing accuracy and timeliness and/or operational reviews to assess administrative processes and controls
? Quickly learn how to navigate insurance company claims, eligibility, provider, medical management systems
? Document findings and write follow-up reports (exhibits and narration)
? Participate in client meetings and depending upon experience, manage client relationships


Years of Experience Required
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4-6+

Education Required
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Bachelor's degree required

Job Requirement Essential
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The ideal candidate will have 5-10+ years of progressive responsibilty in the health care claims review business. Prior consulting experience within a professional services firm is also desirable.
Key skills must include:
? 5+ years insurance company/HMO operations experience (Eligibility, premium billing, claims processing, medical management, provider contracting, underwriting, customer service)
? Solid knowledge of benefit plans (HMO,POS, PPO) and related employer administrative processes
? Understanding of various Medicare benefit approaches (carveout, supplement, risk)
? Knowledge of medical claims coding practices (procedure code/rev code/HCPCS, diagnosis codes, etc) a plus

Personal Skills
? Ability to work on a team and under time pressure
? Strong attention to detail, self-starter
? Excellent written and verbal communication skills
? 60-70% national travel required
? Excellent computer skills, MS Word and Excel
? Flexible to adapt to ever changing priorities
? Can juggle multiple projects concurrently

The candidate should have broad experience in claims administration activities including the use of technology to assess claim processing accuracy (automated testing analysis). The candidate should be able to speak to the key issues currently affecting the U.S. and international insurance marketplace and, specifically, how these issues impact the claims review work.

Minimum qualifications include a Bachelor?s Degree; outstanding writing, public speaking, problem-solving, and project management skills. The candidate must demonstrate a proven ability to interact and communicate effectively across all levels and functions of a client or service provider organization, and a willingness and ability to travel to an insurance coompany/TPA site approximately 2-3 weeks per month.

Travel Required
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60- 80%

Type of Position
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Full Time

Relocation Information
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No