Remote Auditor, Delegate Claims
Alignment Health 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 experienced 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 Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Remote -The Auditor, Delegate Claims, plays a critical role in supporting Alignment Healthcareâs delegated oversight audit program by executing claims related audits, validating compliance with regulatory and contractual requirements, and contributing to the organizationâs transition toward a more proactive, performance focused oversight 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 capacity, 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 partnersâincluding Delegate Performance, internal claims, quality, and complianceâto ensure audit findings are accurate, actionable, and effectively communicated for downstream 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 complex CAP related 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 entitiesâ compliance with CMS and contractual requirements related to claims processing and adjudication.
⢠Maintain organized, auditâready 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 problemâsolving and strengthen oversight effectiveness.
⢠*Perform risk assessment and prioritize audits
⢠Contribute to identifying highârisk 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 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 followâup 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.
⢠Aggregate audit results into departmentâstandard reporting formats for leadership revi
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In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Remote -The Auditor, Delegate Claims, plays a critical role in supporting Alignment Healthcareâs delegated oversight audit program by executing claims related audits, validating compliance with regulatory and contractual requirements, and contributing to the organizationâs transition toward a more proactive, performance focused oversight 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 capacity, 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 partnersâincluding Delegate Performance, internal claims, quality, and complianceâto ensure audit findings are accurate, actionable, and effectively communicated for downstream 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 complex CAP related 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 entitiesâ compliance with CMS and contractual requirements related to claims processing and adjudication.
⢠Maintain organized, auditâready 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 problemâsolving and strengthen oversight effectiveness.
⢠*Perform risk assessment and prioritize audits
⢠Contribute to identifying highârisk 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 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 followâup 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.
⢠Aggregate audit results into departmentâstandard reporting formats for leadership revi
Apply tot his job
Apply To this Job