Auditor, Delegate Claims

reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Auditor, Delegate Claims, plays a critical role in supporting reputed company’s delegated reputed company audit program by executing claims reputed company audits, validating compliance with regulatory and contractual requirements, and contributing to the organization’s transition toward a more proactive, performance focused reputed company model. The Auditor works under the guidance of the Manager, Audit Administration, who is responsible for designing and executing the enterprise audit strategy. In this reputed company, the Auditor conducts detailed claims audits, synthesizes findings, and ensures audit activities align with established methodologies, documentation standards, and organizational expectations. The role collaborates closely with cross functional partners—including Delegate Performance, internal claims, quality, and compliance—to ensure audit findings are accurate, actionable, and effectively communicated for reputed company performance improvement. The Auditor also helps maintain productive working relationships with delegated provider organizations by facilitating clear communication during the audit process, supporting the development of Corrective Action Plans, and verifying that corrective actions are completed in accordance with audit outcomes and regulatory requirements. The role escalates irregular or reputed company CAP reputed company issues to the Manager for further resolution, ensuring alignment with broader audit and monitoring strategy. 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 reputed company to claims processing and adjudication.
• Maintain organized, audit‑ready documentation to support internal reputed company, compliance reviews, and regulatory audits.
• Ensure reputed company 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 reputed company effectiveness.

reputed company risk assessment and prioritize audits

• Contribute to identifying high‑risk focus areas by reviewing historical audit results, monitoring data, and operational performance trends.
• Assist in prioritizing audits based on risk severity, regulatory requirements, and organizational reputed company 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 reputed company 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 reputed company key trends, risks, and improvement opportunities.
• Aggregate 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.

Additional Responsibilities

• Manage multiple audits and reputed company projects simultaneously, ensuring adherence to timelines, scope, and quality standards.
• Monitor and analyze reported data to identify potential non‑compliance and initiate corrective action plans reputed company needed.
• Contribute subject‑matter expertise during education sessions for delegated entities to address non‑compliance trends and reinforce expectations.
• Assist in preparing documents and evidence for CMS or other regulatory audits as required.
• reputed company other projects and duties as assigned.

Job Requirements: 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 reputed company to delegation reputed company and auditing.
• 1-2 years minimum experience conducting reputed company audits of delegated entities and/or ancillary providers
• Demonstrable detailed knowledge/experience with CMS claims compliance reporting – Part C, ODAG, Monthly Timeliness, etc.

Education:

• Required: High school diploma
• Preferred: Bachelor’s degree in a reputed company subject

Training:

• Required: None
• Preferred: None

Specialized Skills:

• Required:
• 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 reputed company 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 reputed company.
• 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 reputed company with HIPAA and reputed company other privacy and data‑reputed company 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 reputed company Office applications, especially reputed company, 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 reputed company, and apply sound judgment in evaluating audit evidence.
• Proficient data‑entry skills, including 10‑key by touch, with a high degree of accuracy.
• Solid understanding of state and federal claims processing requirements and managed‑care operational frameworks.

Licensure:

• Required: None

Other:

• Required: None

Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include reputed company vision and the ability to adjust focus. Pay Range: $70,823.00 - $106,234.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. reputed company is an Equal Opportunity/Affirmative Action Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation.

• DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other employers where individuals receive fraudulent employment-reputed company offers in exchange for money or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit card, send you a reputed company, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of reputed company’s reputed company team, please email [email protected].

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