Remote Auditor, Delegate Claims

Job Duties/Responsibilities

• Conduct audits in accordance with regulatory, contractual, and industry standards
• Execute detailed claims audits using established methodologies, sampling frameworks, and documentation standards to ensure accuracy, consistency, and regulatory readiness
• Assess delegated entities’ compliance with CMS and contractual requirements related to claims processing and adjudication
• Maintain organized, audit-ready documentation to support internal oversight, compliance reviews, and regulatory audits
• Ensure all audit activities align with the enterprise audit strategy set by the Manager, Audit Administration
• Engage delegated provider organizations to correct deficiencies and improve performance
• Communicate audit scope, expectations, and timelines clearly to delegated provider organizations throughout the audit lifecycle
• Provide delegates with clear explanations of audit findings, including root causes, compliance gaps, and potential operational impacts
• Support delegated entities in developing corrective actions and understanding expectations for improvement, fostering a collaborative and transparent working partnership
• Promote productive and professional relationships to drive joint problem-solving and strengthen oversight effectiveness
• Perform risk assessment and prioritize audits
• Contribute to identifying high-risk focus areas by reviewing historical audit results, monitoring data, and operational performance trends
• Aid in prioritizing audits based on risk severity, regulatory requirements, and organizational oversight needs
• Provide input to refine audit scope and schedules to ensure timely and effective audit execution
• Escalate emerging risks or irregular patterns to the Manager for strategic inclusion in future audit planning
• Validate Corrective Actions are effective
• Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses identified deficiencies
• Assess evidence provided by delegates (e.g., workflow changes, documentation updates, system modifications) to confirm compliance with regulatory and contractual standards
• Track CAP progress and ensure required follow-up is completed and documented
• Escalate irregular, incomplete, or stalled CAPs to the Manager, Audit Administration to support timely resolution
• Report audit findings to facilitate organizational awareness
• Prepare clear, concise, and accurate audit summaries that highlight key trends, risks, and improvement opportunities
• Agregate audit results into department-standard reporting formats for leadership review and cross-functional communication
• Partner with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal teams to ensure findings are understood and actionable
• Support preparation of materials for internal committees, regulatory bodies, and enterprise risk-management forums

Experience

• 3-5 years of claims experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of claims aspects of managed care operations
• Prior Medicare Managed Care claims experience related to delegation oversight and auditing
• 1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers
• Demonstrable detailed knowledge/experience with CMS claims compliance reporting – Part C, ODAG, Monthly Timeliness, etc.

Education

• High school diploma

Specialized Skills

• Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing delegated claims operations
• Exceptional organizational skills with the ability to maintain accurate, complete, and audit-ready documentation across multiple concurrent workstreams
• High attention to detail with strong analytical and problem-solving capabilities to evaluate data, identify patterns, and determine root causes of issues
• Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight
• Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally
• Ability to maintain confidentiality and comply with HIPAA and all other privacy and data-security standards
• Strong interpersonal skills and the ability to build positive, productive working relationships with co-workers, internal stakeholders, delegated entities, and external partners
• Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work
• Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook, and the ability to use these tools to analyze data, document audit findings, and support reporting needs
• Working knowledge of medical terminology, claims processing systems, and claims coding structures (CPT, RVS, ICD-10, HCPCS)
• Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence
• Solid understanding of state and federal claims processing requirements and managed-care operational frameworks

Pay Range

$70,823.00 - $106,234.00