Grievance & Appeals Auditor I

Job Summary

The Grievance and Appeals (G&A) Auditor is responsible for performing end-to-end audit of appeals and grievance cases. This role ensures compliance with applicable regulatory requirements, including standards established by the Centers for Medicare & Medicaid Services (CMS). The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations, and timeliness standards, while identifying opportunities for process improvement and risk mitigation.

Responsibilities

• Conduct pre- and post-resolution audits of member appeals and grievance cases across Medicare Advantage and other managed care lines of business.
• Ensure compliance with CMS Medicare Advantage Appeals and Grievance regulations, internal policies, and regulatory timeframes.
• Review case files for accuracy and completeness, including:
  • Member eligibility and benefit coverage
  • Medical necessity determinations
  • Clinical rationale and supporting documentation
  • Benefit interpretation and plan policy application
  • Provider and member communications
• Validate that appropriate clinical and administrative review levels were applied throughout the appeals and grievance lifecycle.
• Assess adherence to CMS requirements for notices, including denial letters, appeal determinations, and grievance responses.
• Identify procedural errors, compliance gaps, and documentation deficiencies.
• Evaluate timeliness of case resolution against regulatory standards.
• Document audit findings with clear rationale, regulatory citations, and impact assessments.
• Support audit readiness and regulatory examination activities.
• Prepare detailed audit reports outlining:
  • Case review findings and decision accuracy
  • Procedural and compliance deviations
  • Financial, operational, or regulatory risk exposure
• Track audit outcomes to identify trends in appeals and grievance processing errors.
• Support reporting for compliance committees, regulatory audits, and internal quality initiatives.
• Provide feedback to Grievance and Appeals teams regarding identified errors and improvement opportunities.
• Recommend corrective actions, training needs, and process enhancements.
• Identify systemic issues and collaborate with leadership, compliance, and operational teams to implement solutions.
• Escalate potential compliance risks or regulatory violations as appropriate.
• Partner with clinical reviewers, compliance officers, and operational leaders to resolve complex case issues.
• Communicate audit findings clearly to both technical and non-technical stakeholders.