Conduct comprehensive claims audits to ensure compliance with fee schedules, benefit plans, contractual obligations, service-level agreements, and claim turnaround standards. Evaluate claims processing activities for adherence to industry best practices, federal and state regulatory requirements, organizational policies and procedures, provider contracts, and applicable accreditation standards.
Analyze audit results, identify trends and areas of risk, and prepare detailed written reports summarizing findings, root causes, and recommendations for corrective action and process improvement. Collaborate with internal stakeholders to monitor compliance, improve operational effectiveness, and support regulatory readiness.
MercyCare administers a diverse portfolio of health insurance products, including Medicaid, Exchange, ERISA, and commercial plans, and operates within regulatory frameworks established by the Wisconsin Office of the Commissioner of Insurance (OCI), Illinois Department of Insurance (DOI), and other applicable federal and state agencies. The role requires a strong understanding of health plan operations, claims administration, and regulatory compliance across multiple lines of business.
Essential Duties and Responsibilities
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Conduct audit interviews with front line staff in all functional areas that fall under claim operations.
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Test, create flow charts and map operational processes that touch the outcome of claims accuracy.
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Perform routine and moderately complex audits on claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration.
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Research claim processing issues and errors to determine their origin and appropriate resolution. Interacts with Operations management regarding trends in order to improve claims processing accuracy and incorporate into training programs, policies and procedures.
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Create audit reports to document audit findings, which will result in audit recommendations, reports and claims audit criteria enhancements.
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Perform special project audits and reviews as requested by other departments.
Education and Experience
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Bachelor's degree in accounting or business administration preferred with concentration in health care also preferred.
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Minimum 2 years audit experience in health care industry.
Certification and Licensure
The following certifications are preferred:
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Certified Internal Auditor (CIA) certification
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Certified Healthcare Auditor (CHA)
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Certified Public Accountant (CPA)
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Registered Health Information Administrator (RHIA)
Skills and Abilities
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Effective written and oral communication skills.
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Excellent analytical/interpretive skills.
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High degree of accuracy.
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Proficiency in application of computers and software programs such as Excel.
PAY RANGE:
$58,797.66 - $94,076.26
Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.
Mercyhealth offers competitive pay and a comprehensive benefits package including:
Medical, Dental, Vision
Life & Disability Insurance
FSA/HSA Options
Generous, accruing paid time off
Paid Parental and caregiver leave
Career advancement and educational opportunities
Tuition and certification reimbursement
Certification Reimbursement
Well-being Programs
Employee Discounts
On-Demand Pay
Financial Education
Annual recognition/awards events
Partner appreciation days
Family entertainment/attractions discount
Community service/improvement opportunities
Click here for more details regarding Mercyhealth Careers Benefit Information.
At Mercyhealth, we don’t simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.
Mercyhealth has been nationally recognized for our commitment to our people and culture, including:
#1 in the nation on AARP's Best Employers for Workers Over 50
One of Working Mother magazine's 100 Best Companies for Working Mothers
A Top 50 Company and Top 10 Nonprofit for Executive Women
