Private Medical Plan Auditor

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Private Medical Plan Auditor

Risk & Compliance

Company:

Description:

Mercer Marsh Benefits (MMB) are looking for a Private Medical Plan Auditor to join our Workplace Health team in London, although for the right candidate we may consider candidates based from our other UK offices. This is a hybrid working role, with a requirement work three-days per week in the office.

Role overview - To provide independent oversight of our clients’ Private Medical Trust’s claims processing performed by the Third-Party Administrator (TPA), ensuring claims authorisation decisions and payments are accurate and compliant with the scheme benefit design, authorisation requirements, applicable fee schedules/tariffs, and internal controls. The role also reviews the quality of the member claims experience through their interaction with the TPA.  The role identifies areas of digression from the benefit design or authorisation requirements, supports recoveries/corrections where appropriate, makes recommendations to improve end-to-end claims quality and the member experience through insight and corrective actions.

We will count on you to:

Audit delivery & claims quality

• Develop and deliver a risk-based audit report across claim types (e.g., inpatient/day case, outpatient, diagnostics, therapies, mental health, oncology, etc.) aligned to the Trust’s governance priorities and agreed audit scope.

• Perform post-payment audits of TPA claim decisions and payments to validate:

  • member eligibility and scheme participation at date of service

  • benefit entitlement, limits, cost shares (excess/co-insurance), waiting periods, exclusions, etc.

  • adherence to pre-authorisation/referral requirements and applicable clinical/case management pathways

  • quality of the member experience when corresponding with the claims service and pathways.

• Validate the accuracy of claim set-up and adjudication (including documentation completeness, correct benefit selection, and correct application of tariffs/fee schedules, network rules, etc.).

• Identify, evidence and quantify issues including over/under-payments, duplicate payments, non-covered services, miscoding/upcoding, unbundling, and processing/administrative errors.

Reporting, insight & client delivery

• Organise disparate information into structured findings, analyse audit outcomes to identify root causes, repeat errors, and control weaknesses; translate these into practical recommendations to improve TPA processing quality.

• Produce clear, client-ready audit reports and summaries outlining findings, financial impact, trends, and corrective actions.

• Present audit findings and recommendations to Trust/client stakeholders in a confident and professional manner.

Data Privacy & Confidentiality

• Handles sensitive health data and Trust financial information; must comply with all applicable data protection and information security requirements

What you need to have:

• Solid experience in PMI claims operations (TPA and/or insurer environment), with exposure to claims decisioning, authorisations and claims assessment; prior claims quality/audit experience preferred.

• Strong working knowledge of PMI benefits and scheme rules, gained through claims assessment and / or authorisation.

• Attention to detail is essential.

• Proficient in Microsoft tools. 

• Project management: Coordinating tasks, timelines and deliverables across multiple client workstreams.

• Scope development: Collecting and documenting client needs to support project scope and audit focus.

• Stakeholder coordination: Liaising with internal teams, TPA and client contacts to keep projects aligned and progressing.

• Data gathering: Requesting, obtaining and interpreting insurer information to support case analysis and audit findings

What makes you stand out:

• Exposure to high-cost/complex claims and provider billing practices.

• Familiarity with audit methodologies (sampling, root cause analysis, control testing).

• Claims/insurance qualifications (local equivalent) and/or medical billing/coding familiarity.

• Understanding of UK employee benefits, in order to integrate audit findings and recommendations into the client’s wider benefit design.           

Why join our team:

• We help you be your best through professional development opportunities, interesting work and supportive leaders.

• We foster a vibrant and inclusive culture where you can work with talented colleagues to create new solutions and have impact for colleagues, clients and communities.

• Our scale enables us to provide a range of career opportunities, as well as benefits and rewards to enhance your well-being.