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City of New York · 2 months ago

Self-Funded Health Plan Auditor

Manhattan, NY

Full-time

Onsite

Entry, Mid Level

$68K/yr - $96K/yr

1+ years exp

The City of New York is responsible for labor relations and health benefits administration, and they are seeking a Self-Funded Health Plan Auditor. The role involves monitoring health plan compliance, validating claims data, planning and executing audits, and resolving discrepancies in payment data.

GovernmentLegalPublic Relations

Responsibilities

Monitor Health Plan Compliance:

Review and audit of self-funded health plan financial processes to ensure compliance with contractual obligations, regulatory requirements, and internal policies related to the payment of daily healthcare claims and monthly administrative fees

Claims Data Validation:

Verify the accuracy, completeness, and timeliness of daily healthcare claims payment data submitted by the health plan prior to authorize payment. Perform monthly reconciliations between the daily claims reports and the monthly reports which detail claim associated fees to ensure compliance with contractual obligations, regulatory requirements, and internal policies prior to payment being authorized

Audit Planning and Execution:

Coordinate with the external auditor and health plan administrators to develop and execute audit of City self-funded health plan. Coordinate review of audit reports outlining findings, root causes, and recommendations. Assist in maintaining readiness for external audits or regulatory reviews

Discrepancy Resolution:

Investigate anomalies or discrepancies in payment data, including duplicate payments, misclassifications, and ineligible charges

Qualification

Health Plan ComplianceClaims Data ValidationAudit PlanningDiscrepancy ResolutionInsurance Experience

Required

A baccalaureate degree from an accredited college or university plus one year of full-time paid experience within the last six years in fire, casualty or surety insurance as a corporate insurance manager, insurance agent, insurance underwriter or insurance broker

High school graduation or evidence of having passed an examination for the high school equivalency diploma or the U.S. Armed Forces G.E.D. certificate with a score of at least 35 on each of the five tests and an overall score of at least 225 in the examination for the certificate plus five years of satisfactory experience within the last six years as described in (a) above

A satisfactory equivalent combination of education and experience. However, all candidates must be high school graduates with at least one year of experience in the last six years as described in (a) above