Private Medical Plan Auditor

Overview

In this role, you will provide independent oversight of Private Medical Trust claims processed by a TPA to ensure accuracy and adherence to benefit design and controls. You will assess claim decisions, identify digressions from rules, and drive improvements in end-to-end claims quality and member experience. You’ll deliver risk-based audits, translate findings into actionable recommendations, and communicate results to stakeholders. This role sits in Mercer’s Workplace Health team in London, with hybrid working and opportunities to influence client outcomes and claims processes.

Pay / Benefits

• hybrid work
• professional development opportunities
• supportive leaders
• inclusive culture
• career opportunities
• benefits and rewards to enhance well-being

Responsibilities

• Develop and deliver risk-based audit reports across claim types aligned to governance priorities
• Perform post-payment audits of TPA claim decisions and payments verifying eligibility, entitlement, and tariff adherence
• Validate accuracy of claim setup and adjudication including documentation and network rules
• Identify issues such as over/under-payments, non-covered services, and coding errors; support corrective actions
• Organise findings into structured reports; analyse root causes and control weaknesses; provide practical recommendations
• Produce client-ready audit reports and summaries with findings, financial impact, trends and actions
• Present findings to Trust/client stakeholders in a confident, professional manner
• Handle sensitive health data complying with data protection requirements

Key requirements

• PMI claims operations experience (TPA and/or insurer environment) with exposure to decisioning and authorisations
• Strong knowledge of PMI benefits and scheme rules
• Attention to detail
• Proficient in Microsoft tools
• Project management: coordinating tasks across client workstreams
• Scope development: documenting client needs for audit focus
• Stakeholder coordination with internal teams, TPA and clients
• Data gathering: obtaining and interpreting insurer information for analysis

• Attention to detail (explicit)
• Stakeholder coordination and liaison
• Analytical thinking and problem solving
• PMI claims operations
• Audit methodologies (sampling, root cause analysis, control testing)
• Claims decisioning and authorisation processes

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