Lead Audit Specialist - Remote

Overview

This role involves leading and coordinating all phases of external regulatory audits across Medicare Advantage, Medicare Part D, Medicaid Managed Care (including Child Health Plus), and Commercial plan products (both on and off exchange). The position ensures timely and accurate data submissions and manages the full audit lifecycle, including RADV audits, Part C & D Data Validation audits, and other regulatory reviews.

Responsibilities

• Manage coordination of HHS ACA RADV IVA Audits, CMS Medicare Advantage contract-level RADV Audits, and Commercial on/off exchange product audits, including HCC validation, Demographic and Enrollment (D&E) validation, and Pharmacy Claims (RXC) validation across all applicable HIOS IDs.
• Oversee external Medicare, Medicaid (including Child Health Plus), and commercial product-related audit efforts from CMS, HHS OIG, NYS DOH, NYS OMIG, NYS Department of Finance, and NYS Office of the State Comptroller.
• Coordinate multiple departments supporting audit responses.
• Lead the full audit lifecycle: announcements, entrance/exit conferences, onsite activities, documentation, delivery of findings, corrective action plan collection and tracking, and submission of monitoring reports to regulatory agencies.
• Serve as primary liaison to external auditors, managing onsite visits, documenting meetings, and maintaining electronic audit archives.
• Manage end-to-end audit documentation requests, ensuring timely and secure delivery of data, policies, samples, and other evidence.
• Ensure audits are conducted efficiently with minimal business disruption; recommend and implement process improvements.
• Provide routine audit monitoring reports to CMS and internal leadership; conduct trend analysis and develop audit readiness processes.
• Support and coordinate CMS Part C & Part D IPM, CMS Contract-Level RADV, and HHS OIG RADV audits, including medical record retrieval and validation of claims, encounter, and provider data.
• Develop and refine RADV audit strategies, improve medical record retrieval processes, and reduce coding errors.
• Collaborate with internal teams such as Enrollment, Provider Operations, Provider Relations, Network Management, and Relationship Managers to ensure required information is supplied for audits.
• Implement HHS mandated IVA process changes.
• Work with Medicare Compliance and External Audit leadership on process improvement initiatives.
• Compile data and information for monitoring reports and senior management reporting.
• Support other Compliance Department activities and organizational initiatives as assigned.

Requirements

• Bachelor’s Degree.
• 5 to 8+ years of relevant professional experience.
• Experience in the healthcare industry performing or participating in audits.
• Extensive knowledge of Medicare Advantage and Medicare Prescription Drug Programs; HHS ACA RADV IVA audits; CMS Medicare Advantage contract-level audits; and Commercial on/off-exchange products including HCC, D&E, and RXC validation across all applicable HIOS IDs.
• Experience managing external audit activities for Medicare, Medicaid (including Child Health Plus), and commercial product lines, including audits by CMS and its contractors, HHS OIG, NYS DOH, NYS OMIG, NYS Department of Financial Services, and NYS Office of the State Comptroller.
• Familiarity with regulators’ audit processes and requirements.
• Working knowledge of health insurance operations, including Commercial health insurance, enrollment, and Individual and Small Group coverage.
• Additional experience or specialized training may be considered in lieu of educational requirements.
• Proficiency in Microsoft Office applications (Word, Excel, Access, PowerPoint, Outlook, Teams).
• Strong organizational skills with the ability to prioritize and manage multiple tasks/projects with competing deadlines.
• Strong analytical and problem-solving skills with outstanding attention to detail.
• Leadership and consensus-building skills; ability to negotiate with department heads for timely delivery of audit data and documents.
• Team player with the ability to advise operational areas on audit completion, deliverable submission, and regulatory compliance.
• Excellent verbal, written, presentation, and interpersonal communication skills.
• Ability to arrange work schedule to meet multiple deadlines and travel to various facilities as needed.
• Ability to advise senior management on regulatory reporting, audit trends, vulnerabilities, and risks.

Compensation & Benefits

• Hiring range: $77,760 - $149,040

Location

• Ability to travel to all organizational facilities as needed.