Lead Audit Specialist - Remote

Summary of Job Lead and coordinate all phases of external regulatory audits across Medicare Advantage, Medicare Part D, State Sponsored Products, and Commercial (on and off exchange) plan products, ensuring timely and accurate audit data responses and submissions. Plan, manage, and execute RADV audits, including data analysis to identify required medical records, vendor oversight, project management, and submission of medical records, supporting documents, and data files to CMS.

Lead and coordinate Part C & D Data Validation audits, including stakeholder communication, data collection, quality review, aggregation, and submission of supporting documentation. Provide operational and regulatory guidance to audit stakeholders to prepare for audits, minimize audit risk, and protect the organization from adverse financial impacts related to risk adjustment audits.

Manage vendor relationships and contracts to ensure audit vendors execute in accordance with contractual language, follow best practices and produce accurate and compliant results. Collaborate with regulators, internal SMEs, and cross-functional departments to gather, organize, and deliver required documentation to auditors.

Coordinate organizational responses to audit findings and facilitate timely remediation or corrective action as needed. Ensure overall audit success by delivering required information accurately and on schedule with minimum disruption to operational areas. Principal Responsibilities Manage the coordination of CMS MA contract level RADV Audits, HHS ACA IVA Audits, including HCC validation, Demographic and Enrollment (D&E) validation and Pharmacy Claims (“RXC”) validation for all EHHIOS IDs.

Manage external Medicare, State Sponsored and commercial product-related audit efforts, including audits from CMS and its audit contractors/consultants, HHS, OIG, NYS DOH, NYS OMIG, NYS Dept of Finance and NYS Office of the State Comptroller. Coordinate the efforts of multiple departments that support our response to these audits.

Lead the full audit lifecycle, including announcements, entrance/exit conferences, onsite activities, documentation, delivery of findings, corrective action plan (CAP) collection and tracking, and submission of required monitoring reports to regulatory agencies. Coordinate and organize remote and/or onsite audit activities for live audits by serving as the primary liaison to external auditors, managing onsite and/or remote interview sessions, documenting meeting minutes, and maintaining audit follow-ups.

Manage audit documentation and deliverable requests, including gathering data, universes, policies, sample materials, and other evidence from internal departments; ensure timely, secure delivery to auditors and maintain a complete internal archive of deliverables and communications. Ensure regulatory audits for Medicare, State Sponsored Programs, and Commercial products are conducted efficiently with minimal business disruption; recommend and implement process improvements to streamline audit and compliance operations.

Provide routine audit monitoring reports to CMS and internal leadership as necessary; conduct trend analysis, offer audit planning recommendations, and develop processes to strengthen regulatory compliance and audit readiness. Support and coordinate CMS Part C & Part D IPM, CMS Contract-Level RADV, and HHS IVA RADV audits, OIG audits including managing medical record retrieval, validating claims/encounter/provider data, and tracking all RADV deliverables.

Develop and refine RADV audit strategies, including improvements in medical record retrieval processes and reducing coding errors; manage efforts to enhance RADV audit coordination workflows. Collaborate with internal teams (including, but not limited to Enrollment, Provider Operations, Provider Relations, Network Management, Relationship Managers) to ensure providers, facilities, delegates, and vendors supply required information for all annual government audits as referred to above.

Implement HHS mandated IVA process changes. Work with the Medicare Compliance and External Audit Leader on process improvement initiatives. Compile data and information to support monitoring and dashboard status reporting Senior Management. Support other Compliance Department activities as directed, assigned, or required.

Support organizational initiatives and projects.

Qualifications

Bachelor’s Degree 5 – 8+ years’ relevant, professional work experience (Required) Experience in healthcare industry – performing/participating in government audits (Required) Extensive knowledge of Medicare Advantage and Medicare Prescription Drug Programs; CMS Contract Level RADVs, HHS ACA IVA audits; including HCC validation, Demographic & Enrollment (D&E) validation, and Pharmacy Claims (RXC) validation across all applicable HIOS IDs.

(Required) Experience managing external audit activities for Medicare, State Sponsored, and commercial product lines, including audits conducted by CMS and its contractors, HHS OIG, NYS DOH, NYS OMIG, NYS Department of Financial Services, and the NYS Office of the State Comptroller; familiarity with regulators’ audit processes and requirements (Required) Working knowledge of health insurance operations - understanding of Commercial health insurance, enrollment, and Individual and Small Group coverage, etc.

(Required) Additional experience/specialized training may be considered in lieu of educational requirement (Required) Proficiency in the use of Microsoft Office

• Word, Excel, Access, PowerPoint, Outlook, Teams, etc. (Required) Ability to organize, prioritize, and successfully manage multiple tasks/projects with simultaneous competing deadlines (Required) Strong analytical and problem-solving skills; and outstanding attention to details (Required) Must be a leader and consensus-builder, able to successfully negotiate with Department heads for the timely delivery of audit data and documents (Required) Must be a team player willing to assist, and correctly advise, operational areas on successful completion of audits, submission of audit deliverables and compliance with regulations (Required) Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required) Ability to arrange work schedule to meet deadlines from multiple sources and engage staff throughout Emblem. Health to assist in the completion of duties and to travel to all Emblem. Health facilities as needed (Required) Ability to advise Senior Management on regulatory reporting and audit trends and tactics, as well as Emblem. Health’s audit vulnerabilities and risks.