BRIEF DESCRIPTIONAs a member of our Absence, Disability, and Life team, the Contract Clinical Auditor will perform independent clinical reviews of disability claims. The Auditor will evaluate medical records, determine clinical appropriateness and consistency with policy, identify documentation or clinical gaps, and provide clear, evidence-based findings to support claim decisions, case management, and quality improvement initiatives.
ESSENTIAL DUTIES AND RESPONSIBILITIES include, but are not limited, to the following:
- Perform timely, objective clinical audits of disability claim files (short-term and long-term), including review of medical records, treating provider notes, diagnostic tests, functional assessments, and vocational information.
- Assess clinical validity of impairment and activity/functional limitations versus policy criteria, clinical guidelines, and jurisdictional regulations.
- Document findings clearly and concisely in standardized audit templates, including clinical rationale, citations to guidelines or literature, and suggested next steps (e.g., further medical information, peer review, referral to IME).
- Rate claim decisions for clinical appropriateness and consistency with internal policies and external regulatory requirements.
- Identify documentation gaps, potential over- or under-evaluation of disability, and opportunities for clinical or process improvement.
- Provide clear, professional clinical opinions and recommendations to adjudicators, case managers, and medical directors.
- Maintain confidentiality and comply with data protection, privacy, and regulatory obligations (e.g., HIPAA).
- Meet audit production targets and quality standards; provide written and, when requested, verbal summaries of findings.
- Stay current with relevant clinical practice guidelines, disability medicine literature, and regulatory changes affecting disability adjudication.
- Complete assigned audits within agreed turnaround times.
- Produce audit reports that meet company quality standards.
REQUIRED EDUCATION AND EXPERIENCE:
- Valid, unrestricted clinical license(s) appropriate to role, including MD/DO, NP, PA, RN with specialty in Occupational Health, Rehabilitation, or related field.
- Minimum of 3-5 years clinical experience evaluating functional capacity, disability, or occupational/rehabilitation medicine; experience with disability claims adjudication preferred.
- Strong knowledge of common medical conditions that cause work limitation (musculoskeletal, neurological, mental health, cardiopulmonary), diagnostic testing, and treatments.
- Demonstrated experience interpreting medical records and producing objective, evidence-based clinical opinions.
KNOWLEDGE, SKILLS AND ABILITIES- Prior experience as a clinical auditor, peer reviewer, independent medical examiner (IME), clinical disability case manager, or equivalent.
- Familiarity with disability policy language, benefit plan terms, and regulatory frameworks that affect disability determinations.
- Excellent written and verbal communication skills with the ability to translate clinical findings into clear recommendations for non-clinical audiences.
- Attention to detail, strong critical thinking, and consistent application of clinical standards.
- Comfortable working in a fast-paced, metrics-driven environment and meeting deadlines.
- Proficiency with electronic claims systems, and standard applications, including Microsoft Office Suite.
PHYSICAL DEMANDS AND WORK ENVIRONMENT- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is:
- Frequently required to sit; speak or hear; use hands to finger, handle, feel objects, and reach with hands and arms;
- Occasionally required to stand and walk;
- Extensive use of computer and keyboard and viewing of computer screen is required;
- Specific vision abilities required by this job include vision, and ability to adjust focus.
- Other working conditions are normal for an office environment.
WORK LOCATION - Work is typically performed either remotely or on site at Marsh McLennan Agency's Conshohocken, PA office.
The applicable hourly rate for this role is $175.00.
The base pay offered will be determined on factors such as experience, skills, training, location, certifications, and education. Decisions will be determined on a case-by-case basis.
