Self-Funded Health Plan Auditor

Job Description

The Office of Labor Relations (OLR) represents the Mayor in the conduct of all labor relations between the City of New York and labor unions representing employees of the City. The Commissioner serves on behalf of the Mayor as the City’s liaison with both labor and management in the private sector. The office is authorized by Executive Order 38 (February 7, 1967), amended by Executive Order 13 (July 24, 1990). Additionally, OLR administers the Health Benefits Program, Management Benefits Fund, Employee Assistance Program, Work Well NYC, Medicare Part B Reimbursement Program and Pre-Tax Benefits & Citywide Programs, including the Deferred Compensation Plan and NYCE IRA. In addition to negotiating collective bargaining agreements, OLR serves as a resource to agencies with regard to workforce labor issues and works with the Municipal Labor Committee (MLC) to pursue innovations in a variety of areas, particularly regarding City health insurance programs. The staff at OLR assist their fellow agencies in handling personnel and payroll issues, conducting labor-management meetings, representing the City at representation hearings, and handling all employee grievances and arbitration matters, while also negotiating collective bargaining agreements with the City's 149 bargaining units.

1.Monitor Health Plan Compliance:
Review and audit of self-funded health plan financial processes to ensure compliance with contractual obligations, regulatory requirements, and internal policies related to the payment of daily healthcare claims and monthly administrative fees.

2.Claims Data Validation:
Verify the accuracy, completeness, and timeliness of daily healthcare claims payment data submitted by the health plan prior to authorize payment. Perform monthly reconciliations between the daily claims reports and the monthly reports which detail claim associated fees to ensure compliance with contractual obligations, regulatory requirements, and internal policies prior to payment being authorized.

3.Audit Planning and Execution:
Coordinate with the external auditor and health plan administrators to develop and execute audit of City self-funded health plan. Coordinate review of audit reports outlining findings, root causes, and recommendations. Assist in maintaining readiness for external audits or regulatory reviews.

4. Discrepancy Resolution:
Investigate anomalies or discrepancies in payment data, including duplicate payments, misclassifications, and ineligible charges.

INSURANCE ADVISOR - 40235

Qualifications

a. A baccalaureate degree from an accredited college or university plus one year of full-time paid experience within the last six years in fire, casualty or surety insurance as a corporate insurance manager, insurance agent, insurance underwriter or insurance broker; or
b. High school graduation or evidence of having passed an examination for the high school equivalency diploma or the U.S. Armed Forces G.E.D. certificate with a score of at least 35 on each of the five tests and an overall score of at least 225 in the examination for the certificate; plus five years of satisfactory experience within the last six years as described in (a) above; or
c. A satisfactory equivalent combination of education and experience. However, all candidates must be high school graduates with at least one year of experience in the last six years as described in (a) above.

Additional Information

The City of New York is an inclusive equal opportunity employer committed to recruiting and retaining a diverse workforce and providing a work environment that is free from discrimination and harassment based upon any legally protected status or protected characteristic, including but not limited to an individual's sex, race, color, ethnicity, national origin, age, religion, disability, sexual orientation, veteran status, gender identity, or pregnancy.