- Salary
- $79k – $159k
- Location
- Atlanta - Hartsfield, United States of America
- Workplace
- Remote
- Type
- Full-time
- Department
- Healthcare
- Seniority
- Lead
- Experience
- 5+ years
- Closing date
- Today
- Source
- Workday
Description
Company:
MercerDescription:
Medical Audit Lead
Role Summary
We are seeking a Medical Audit Lead to lead complex medical claims audits from planning through final reporting. This role requires deep expertise in the medical claims payment process, including how claims are billed, processed, adjudicated, and paid. The ideal candidate understands the full structure of a medical claim, can independently identify issues through detailed claim review, and can confidently evaluate and challenge vendor responses when findings are disputed.
This is a highly visible, client-facing role that also requires strong project management skills, the ability to manage multiple priorities, and excellent written and verbal communication. This is a fully remote role.
Key Responsibilities
Lead complex medical claims audits from intake and planning through reporting and client presentation.
Interpret plan documents, benefit provisions, exclusions, pricing methodologies, and administrative terms.
Review and assess medical claims for accuracy, including manual identification of processing and payment issues.
Apply strong knowledge of medical claims adjudication, billing, coding, pricing, edits, and member cost share.
Use audit analytics tools and claim-level review to identify trends, exceptions, and potential errors.
Develop clear, well-supported findings and prepare evidence-based responses to vendor disagreements.
Serve as a primary client contact and communicate audit progress, issues, and results clearly and professionally.
Manage multiple audits and deadlines while maintaining high quality and attention to detail.
Required Qualifications
5+ years of experience in medical claims auditing, medical claims operations, benefits administration, and/or carrier/TPA environments.
Deep working knowledge of the medical claims payment process.
Strong understanding of the core components of a medical claim and the ability to identify issues through manual review.
Demonstrated ability to assess claim accuracy and support defensible audit conclusions.
Experience evaluating and rebutting vendor or carrier responses.
Strong project management and organizational skills.
Excellent client-facing, written, and verbal communication skills.
Bachelor’s degree in healthcare, business, finance, analytics, or a related field, or equivalent experience.
Preferred Qualifications
Experience leading complex audits or large-scale claim review projects.
Experience using audit analytics platforms or SaaS-based audit tools.
Strong Microsoft Office skills.