Senior Health Claims Auditor

Guardian Group
Port of Spain, TT
Competitive salary
Senior Health Claims Auditor
DEPARTMENT / BRANCH: Group Insurance Sales
REPORTS TO: Vice President - Group Insurance Sales
Job Objective
The Senior Health Claims Auditor performs complex, professional level health claims auditing work. This involves leading or conducting performance, financial and compliance audit projects; providing consulting services to the Group's management and staff and providing key input to development of the Annual Audit Plan. He/She works independently under general supervision with considerable latitude for initiative and independent judgment.
Job Responsibilities
1. Create and update the Audit Plan for Group Insurance - Health Claims.
2. Conduct interviews, review documents, develop audit programmes, perform audit procedures, including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting client processes and procedures.
3. Make recommendations for improvement via Review of SOPs, process maps, training material, Quality framework and the Real Time Adjudication Audit Procedure.
4. Supervise the work of staff auditors engaged in the reviews of organizational and functional activities.
5. Identify, develop, and document audit findings, risks and using independent judgment concerning areas being reviewed and obtain risk corrective actions from appropriate level of management.
6. Develop and maintain productive client and staff relationships.
7. Provide training, coaching and guidance to staff in conducting audits and other audit-related issues.
8. Accumulate data, maintain records, and prepares report on the results of audit projects and other assigned activities.
9. Work with the Manager to develop reports to assist in the auditing and monitoring of business
process quality levels.
10. Provide management with the intelligence that lends to informed hypotheses and decision making
where internal processes are concerned.
11. Takes initiative to become familiar with information about claims processing specifically as it relates to best practice, current and emerging risks within the health industry.
12. Provides for a flow of communication from auditee and/or staff auditor to VP - Group Ins Sales.
13. Perform any other job-related duties as assigned by the VP - Group Ins Sales.
* First Degree in Business, Management or Accounting from a recognized tertiary level educational institution.
* LOMA 280, 290, ACS 100 and all related parts
* Certification as a CIA, ACCA, CPA, or CISA.
* Experience in Industry auditing and accounting and/or 2 - 5 years' insurance experience in the Insurance Industry in a claims adjudication role.
The Senior Health Claims Auditor must be hard-working and devoted. He/ She must be honest and must be highly confidential and should possess unquestionable ethics. The Senior Health Claims Auditor must be tactful, well composed and should have good team orientation. The individual must be well organized and very though in order to complete tasks efficiently. He/ She must be very detailed and thorough and must be able to adapt to a very dynamic environment. The Senior Health Claims Auditor must have a very warm and engaging personality and must be able to interact well with others.
N.B. The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities as requested by the Manager from time to time, as needed.

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