Senior Consultant, Health Insurance - Risk Regulatory & Compliance

Senior Consultant, Health Insurance - Risk Regulatory & Compliance

Our Deloitte Regulatory, Risk & Forensic team helps client leaders translate multifaceted risk and an evolving regulatory environment into defensible actions that strengthen, protect, and transform their organizations. Join our team and use advanced data, AI, and emerging technologies with industry insights to help clients bring clarity from complexity and accelerate their path to value creation.

Work You'll Do

As a Senior Consultant on our Insurance and Life Sciences team, you will:
* Review medical records, claims documentation, and benefit materials to support accurate determinations for procedures, treatments, confinements, and applicable benefits
* Conduct appeals reviews for denied or underpaid claims, assess documentation, coding, and policy interpretation issues, and prepare clear review rationales supported by evidence
* 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
* Execute quality control and audit activities, identify root causes, recommend corrective actions, and support process improvements that increase accuracy, consistency, and compliance
* 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

The Team

Our Regulatory & Financial Risk offering supports clients' regulatory and compliance needs, balancing risk and regulatory requirements with enhancing business value and optimizing outcomes. We deliver enhanced value through strategic transformation, end-to-end implementation, and a focus on business-as-usual sustainability across processes, controls, and data & analytic infrastructures.

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

Preferred Qualifications:
* 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

The successful candidate would possess these skills

• 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

Information for applicants with a need for accommodation:

The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Deloitte, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $118700 to $218600.

You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various fac tors, including, without limitation, individual and organizational performance.