Summary
The Mgr – External Audit will lead a variety of audits and advisory engagements and will directly supervise the claim audit team members and external third-party auditors. The role will include leading audits, presenting audit findings, assisting the Audit Coordinator in the day-to-day monitoring and management of findings identified as part of recuring claims quality assurance audits, and identifying root causes and offering recommendations to create positive change with a sense of urgency. Day-to-day responsibilities include, but are not limited to, conducting audit planning and supervising fieldwork, ensuring all work is in compliance with Global Internal Audit Standards and G.E.H.A Internal Audit methodologies, providing expertise and support in the review, research, and analysis of claim exceptions, presentation of audit findings to management, and delivering training to less experienced team members. Adheres to all corporate policies and procedures as well as professional ethical standards.
Contacts include G.E.H.A employees and management at all levels, vendors, business associates, and contractors, including the G.E.H.A independent auditor and the G.E.H.A third-party claims quality assurance auditor to gather information and present findings and recommendations of audits. May have contact with OPM officials and Regulatory Officials.
Duties
- Coordinate and oversee healthcare claim audits with third-party claim administrators and external claim auditors.
- Manage claim audit team members and provide claim expertise and guidance, assign tasks. Hold direct reports accountable for producing quality and timely results.
- Leads the planning, budgeting, testing, and reporting phases of engagements and prioritizes assignments to ensure projects are completed within expected timeframes and on budget.
- Manages multiple projects or project teams concurrently with limited supervision. Proactively identifies needs and develops solutions.
- Monitors progress, assesses and manages risk factors, and ensures Internal Audit leadership and business stakeholders are kept informed about progress, observations, and expected outcomes.
- Performs quality review of workpapers and other audit deliverables helping to ensure all work is completed timely and in compliance with Global Internal Audit Standards and G.E.H.A Internal Audit methodology.
- Prepares or performs preliminary review of draft audit or review reports, which include the development of clear, constructive, and actionable recommendations to address root cause and risks identified.
- Communicates or assists in communicating the results of audit via written reports and presentations to management, the Board of Directors, and external parties.
- Facilitates communications between internal and external partners to ensure the timely resolution to claim audit questions and exceptions.
- Monitors open audit findings and resolution efforts for compliance with established remediation plans and follows up with business partners, as necessary.
- Fosters and maintain a strong, collaborative relationship with internal and external stakeholders.
- Leads quality after-action reviews or postmortem sessions to capture lessons learned.
- Assists with Ad Hoc projects as requested.
Education Requirements
Requires a college degree (BA/BS) from an accredited college/university.
Experience Requirements
- Requires 5 to 8 years of relevant audit and/or claim processing experience and 3 or more years of leadership experience.
- Must possess a superior level of:
- Analytical, research, and critical thinking skills with the ability to establish facts, define problems, draw valid conclusions, and develop solutions.
- Project, organizational, and time management skills to ensure projects are completed timely and on budget.
- Leadership skills with the ability to motivate, influence, and persuade. Willing to take a position that challenges the prevailing opinion.
- Verbal, written, and interpersonal communication skills and ability to address a wide range of audiences.
- Proficiency in Microsoft Office Applications (Excel is critical).
- Must have a working knowledge of claims processing, medical terminology, medical codes, and reference materials.
- Must have knowledge of or experience with the following areas: Claim system configuration, Claims (Medical/Dental), Enrollment, or Internal Operations functions.
- Ability to work independently, prioritize workflow, and exercise sound and independent judgment seeking guidance where appropriate.
Preferred
Experience with data analytics software and tools preferred, i.e., IDEA, PowerBI, SQL.
GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. We celebrate diversity and are committed to creating an inclusive environment for all employees.
