We are looking for an experienced audit expert and leader with technical acumen that can deliver on Risk Strategies Consulting’s (RSC’s) mission for innovation in audit across medical, pharmacy, value-based care, and drive the development of comprehensive market leading audit solutions. The ideal candidate has a curiosity for innovation with extensive experience in auditing across medical and pharmacy, health plan experience, large claims, stop/loss, and technical acumen in coding/building audit automation. In this role, this candidate can leverage their understanding of audit principles and framework to drive thought leadership and innovate, leveraging their technical skills and experience to create audit solutions that can address the needs of the evolving healthcare landscape. The candidate must be adept with data and analytics and will be responsible for operational audit capabilities. The candidate must have a proactive approach to work, a problem-solving aptitude, and be willing to learn and adapt. The candidate will be motivated, well-organized, and a self-starter that thrives in a fast-paced and dynamic work environment.
Primary Duties & Responsibilities:
- Leverage best practices and audit principles with experience across audit processes in medical, large claims, pharmacy, compliance, and value-based concepts to create methodologies that can drive innovation with improvements or new frameworks to create auditable performance metrics.
- Collaborate with cross-functional teams to create innovative solutions for improving audit processes, technical automation, and integrate concepts that can address complexities in auditing of risk arrangements.
- Develop a short, mid, and long-term growth plan with a clear vision for success.
- Provide expertise in areas of medical, pharmacy, technical coding, and healthcare audit solutions with insights to current landscape, areas of opportunities, and solution opportunities.
- Design, provide technical coding, and develop systematic audits capturing provider billing patterns, practice patterns, and referral patterns influencing overpayments or contributing to waste.
- Develop approach and framework to addressing metrics inclusive of network performance, experience, cost, and efficacy.
- Define measures of success and develop tools that demonstrate the success of audit solutions to enable effective controls, address gaps, and provide ROI validation.
- Monitor the effectiveness of healthcare audit solutions and make improvements based on data insights.
- Utilize data analytics and business intelligence tools to identify patterns, anomalies, and emerging trends and risks specific to the healthcare industry.
- Leverage experience to drive construct and execution of operational audit capabilities.
- Ensure latest technologies and trends are leveraged for data model design, consultations, and customer engagement.
- Enhance existing and introduce new audit capabilities, best practices, work products, functions, and concepts.
- Create structure, process efficiencies, standard operating procedures, and documentation of specifications and requirements to effectively scale the breadth and depth of our audit functions.
- Develop comprehensive audit planning across RSC and deliver work products timely based on established milestones and deadlines.
Requirements & Qualifications:
- Bachelor’s degree in business, Healthcare, or related discipline.
- 5+ years Healthcare experience.
- 5+ years medical and pharmacy audit experience
- 5+ years Audit experience for health plan
- 3+ years Healthcare (medical/pharmacy) coding experience
- 3+ years technical experience with data analysis, including SQL and Python.
- 3+ Value based contracting/arrangement auditing experience.
- Clinical collaboration experience
- Computer proficiency including Microsoft Office (Word, Excel, Outlook, Access).
- 5+ years of experience in claims auditing, quality assurance, or recovery auditing.
- At least 3 years of experience in a leadership role.
- Adept with data and analytics in order to drive efficient audit function/process
- Proven success in managing healthcare products from inception to launch.
- Experience innovating within the audit process for health plans and healthcare providers to reduce costs, streamline processes and remove waste for administrative transactions.
- Extensive knowledge of healthcare data as hospital/physician /ASC claims, utilization data, and healthcare industry coding systems ICD-10, CPT/HCPCS, Revenue Codes, MS/APR-DRGs and APC.
- A strong background in medical and pharmacy healthcare finance, contracting, network management, operations, billing, stop-loss, claim and performance auditing, compliance, and quality standards.
At Risk Strategies Company, base pay is one part of our total compensation package, which also includes a comprehensive suite of benefits, including medical, dental, vision, disability, and life insurance, retirement savings, and paid time off and paid holidays for eligible employees. The total compensation for a position may also include other elements dependent on the position offered. The expected base pay range for this position is between $151,000 - $250,000 annually. The actual base pay offered may vary depending on multiple individualized factors, including geographical location, education, job-related knowledge, skills, and experience.
Risk Strategies is the 9th largest privately held US brokerage firm offering comprehensive risk management advice, insurance and reinsurance placement for property & casualty, employee benefits, private client services, as well as consulting services and financial & wealth solutions. With more than 30 specialty practices, Risk Strategies serves commercial companies, nonprofits, public entities, and individuals, and has access to all major insurance markets. Risk Strategies has over 100 offices and nearly 5,000 employees across the US and Canada.
Our industry recognition includes being named a Best Places to Work in Insurance for the past five years (2018-2022) and on the Inc. 5000 list as one of America’s Fastest Growing Private Companies. We are committed to being good stewards for our company, culture, and communities by having a strong focus on Environmental, Social, and Governance issues.
Risk Strategies is an equal opportunity workplace and is committed to ensuring equal employment opportunity without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics. Learn more about working at Risk Strategies by visiting our careers page: www.risk-strategies.com/careers.
