Senior Consultant, Health Insurance – Risk Regulatory & Compliance

Deloitte Deloitte · Consulting

This role is for a Senior Consultant in Health Insurance focusing on Risk, Regulatory, and Compliance. The responsibilities include reviewing medical records and claims, conducting appeals reviews, applying medical coding standards, and executing quality control activities. The role also involves developing training materials and collaborating with teams. While the job description mentions using 'advanced data, AI, and emerging technologies,' the core responsibilities are centered around traditional healthcare claims review, coding, and compliance, not the direct development or implementation of AI/ML models.

What you'd actually do

  1. Review medical records, claims documentation, and benefit materials to support accurate determinations for procedures, treatments, confinements, and applicable benefits
  2. Conduct appeals reviews for denied or underpaid claims, assess documentation, coding, and policy interpretation issues, and prepare clear review rationales supported by evidence
  3. Apply medical coding standards and claims artifacts, including International Classification of Diseases, Tenth Revision (ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), UB-04, Health Care Financing Administration (HCFA) claim forms, and Explanation of Benefits documents
  4. Execute quality control and audit activities, identify root causes, recommend corrective actions, and support process improvements that increase accuracy, consistency, and compliance
  5. Develop training materials, share medical documentation and coding guidance with team members, and collaborate across United States and United States India teams to meet client expectations and service level agreements

Skills

Required

  • Bachelor's degree in Health Information Management, Healthcare Administration or a related field
  • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS)
  • 8+ years of experience in the United States health care or health insurance industry, including claims review, claims appeals, medical billing and coding, utilization management, or payment integrity
  • Experience applying International Classification of Diseases, Tenth Revision (ICD-10), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) in claims, medical record, or appeals reviews
  • Ability to work business hours aligned to the Eastern Time Zone
  • Ability to travel 50%, on average, based on the work you do and the clients and industries/sectors you serve.
  • Ability to work independently and collaborate as part of a team
  • Effective written and verbal communication skills
  • Meticulous attention to detail and quality of work product
  • Ability to build and sustain professional relationships
  • Ability to lead projects or workstreams
  • Ability to manage and prioritize multiple tasks in a fast-paced and dynamic environment
  • Strong interpersonal skills and professional demeanor
  • Ability to meet deadlines
  • Ability to provide clear guidance to others

Nice to have

  • Experience supporting supplemental insurance claims or appeals reviews
  • Experience reviewing operative reports, medical charts, Explanation of Benefits documents, UB-04 forms, or Health Care Financing Administration (HCFA) claim forms
  • Experience preparing audit workpapers and traceable evidence for quality control, compliance, or regulatory review
  • Experience developing or delivering training on medical documentation, coding updates, or appeals procedures
  • Experience working across distributed delivery teams in the United States and India

What the JD emphasized

  • Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.