Senior Consultant managing ITGCs for SOX and Internal Audit at Armanino. Leading client engagements and mentoring junior staff while ensuring compliance and quality audit processes.
AC
Hybrid Medical Claims Consultant – Part Time
Posted 3 weeks ago
About the role
- Medical Claims Consultant providing medical and business expertise for contestable claims decisions. Collaborating with claims team and ensuring compliance with policy guidelines.
Responsibilities
- Serve as a resource to the contestable claims team.
- Review of medical documentation including physician and hospital records, accident reports or other clinical materials.
- Review and understanding of policy language – interpret policy exclusions and endorsements in relation to medical findings.
- Review all contestable claim denials, including those that may have potential to result in litigation.
- Identify inconsistencies or gaps in medical documentation and recommend additional information when needed.
- Assist in determining whether a claim is eligible under policy language and with respect to any supporting medical documentation.
- Provide training for claims examiners on medical topics relevant to claims decision making.
- Collaborates closely with claims examiners, underwriters, legal counsel and potentially third parties to ensure accurate and fair claims decisions.
- Maintain up-to-date knowledge of relevant medical standards, diagnostic/treatment guidelines, and regulatory/industry developments that impact claim adjudication.
Requirements
- Doctorate or Advanced healthcare degree (MD, DO, BA-PA (Physician Assistant Bachelor’s Degree in conjunction with PA certification), PA-C, NP, RN) with demonstrated claim-consulting or clinical review experience
- Clinical experience (min 5-10 years) with a strong familiarity of a broad range of medical conditions, treatments or outcomes
- Excellent ability to interpret and synthesize complex medical records, and to translate findings into actionable claims decisions.
Benefits
- Reasonable accommodation will be made for otherwise qualified applicants as needed to enable them to fulfill these requirements.
- We are committed to ensuring equal employment opportunities for all job applicants and employees.
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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