Medical Audit Lead

Company:

Description:

Role Summary

Leads end-to-end medical benefit audits, leveraging advanced analytics and third-party Software as a Service (SaaS) platform to review claims, select defensible representative samples, and deliver accurate, client-ready reports while directing and collaborating with audit team members performing the same core audit tasks.

Role Overview

The Medical Audit Lead is accountable for the planning, execution, quality, and delivery of complex medical claims audits. This role serves as the day-to-day audit owner, translating scope and plan provisions into actionable audit work, overseeing analytics-driven claim review activities, resolving vendor disputes, and presenting clear, defensible reports to clients.

Medical Audit Leads conducts audits and/or works with audit professionals who perform the same core claim review, documentation, and quality activities, regardless of location. All audit resources are held to the same standards, methodology, and expectations.

Primary Responsibilities

Audit Intake, Planning & Scope Translation

• Review audit Statements of Work (SOWs), and client objectives to confirm feasibility, timing, and alignment.
• Identify key audit risks based on plan design, vendor history, and prior audit experience.
• Clarify assumptions, exclusions, and dependencies to prevent scope drift.
• Translate approved scope into a detailed carrier scope letter.

Plan Document & Benefit Interpretation

• Perform in-depth review of Summary Plan Descriptions (SPDs), plan documents, amendments, Administrative Services Only (ASO) agreements, and related policies.
• Interpret benefit provisions, exclusions, pricing methodologies, cost-sharing, and administrative terms.
• Document benefit interpretations and provide clear written guidance applicable to all auditors.
• Resolve ambiguous provisions using audit precedent and professional judgment.

Audit Methodology & Sampling

• Lead audits conducted using third-party SaaS platform that analyzes 100% of claims to identify exceptions, trends, and risk areas.
• Use SaaS outputs to identify systemic issues and high-risk claim populations.
• Select defensible, representative samples within the SaaS platform for carrier review.
• Ensure sample selection reflects identified risks, supports audit objectives, and is clearly documented.
• Confirm methodology and sampling approach meet Mercer standards and withstand client and carrier scrutiny.

Data & Programming Coordination

• Validate completeness, accuracy, and timeliness of data prior to SaaS processing.
• Review SaaS analytical outputs for reasonableness and alignment with audit scope.
• Reconcile SaaS results to source data and plan provisions.
• Identify, document, and resolve data anomalies prior to claim-level follow-up.
• Maintain direct access to the SaaS platform for:
  • Sample selection
  • Quality assurance and validation
  • Report and exhibit generation
• Validate SaaS-generated outputs prior to inclusion in client or carrier-facing materials.

Claim Review Oversight & Execution (Analytics-Driven)

• Direct and perform claim-level review activities derived from SaaS analytics and selected samples.
• Ensure all auditors apply consistent methodology, documentation standards, and professional judgment.
• Validate claim determinations against plan provisions, SaaS findings, and supporting documentation.
• Distinguish isolated processing errors from systemic issues using combined analytics and claim review.
• Document conclusions and rationale clearly to support defensible audit outcomes.

Audit Team Coordination & Quality Management

• Provide clear instructions, examples, and expectations applicable to all auditors.
• Review work for accuracy, completeness, and consistency with methodology.
• Provide structured feedback to reinforce quality and reduce rework.
• Serve as the final quality checkpoint prior to reporting and vendor engagement.

Findings Development & Carrier Resolution

• Document audit findings clearly, including root cause, financial impact, and supporting evidence.
• Lead preliminary findings discussions with carriers.
• Evaluate carrier responses and rebuttals using professional judgment.
• Determine final disposition of findings and document rationale.

Client Communication & Relationship Management

• Serve as the primary day-to-day client contact throughout the audit.
• Provide proactive bi-weekly status updates and early risk identification.
• Clearly explain electronic audit methodology, SaaS analytics, and sample rationale to clients.

Reporting & Presentation

• Generate and validate SaaS-based reports and exhibits.
• Author and finalize medical audit reports in accordance with Mercer standards.
• Ensure reports are accurate, well-organized, and client-ready.
• Present audit results to clients and internal stakeholders.

Quality Control, Risk Management & Mentorship

• Apply quality and risk standards throughout audit delivery.
• Participate in peer review of all facets of an audit, including audit reports.
• Mentor auditors and support onboarding and skill development.
• Identify recurring issues and recommend process improvements.

Required Qualifications

• Bachelor’s degree in healthcare, business, finance, analytics, or related field.
• 7+ years of experience in medical claims auditing, benefits administration, carrier/TPA operations, or healthcare consulting.
• Demonstrated experience leading analytics-driven or electronic medical audits.
• Experience using audit analytics platforms or SaaS tools for claim analysis and reporting.
• Strong working knowledge of medical claims adjudication and plan design.
• Excellent written and verbal communication skills.