Specialty Health Plans Auditor III, Claims

• Partner with a prominent managed healthcare organization contributing to a mission-driven environment focused on delivering high-quality, compliant health services to diverse communities.
• This organization is committed to operational excellence and adherence to rigorous regulatory standards, ensuring members receive the best possible care.

Make a direct impact on the integrity and compliance of our health plan operations!

• This pivotal role offers a unique opportunity to directly influence the financial accuracy and regulatory adherence of our specialized health programs.
• You will safeguard our commitment to regulatory standards and contractual agreements, directly impacting the quality of service provided to members and ensuring the financial health of our programs.
• Your expertise will drive critical audit functions, shape policy, and mentor colleagues, making a tangible difference in our continuous pursuit of excellence.

You will:

• Lead all aspects of planning, execution, reporting, and corrective action monitoring for claims processing compliance across specialized health programs and their partners.
• Audit a range of services including:
  
  
  
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    Medical

  • Vision
  • Dental
  • Behavioral health
  • Transportation
  • Telehealth
  
  
  
  
• Ensure delegated entities adhere to applicable regulatory requirements and contractual agreements across all lines of business.
• Manage critical regulatory data submissions.
• Oversee annual review and update of departmental policies and procedures.
• Act as a Subject Matter Expert and mentor for other staff, shaping best practices and fostering continuous improvement.

• Conduct annual claims audits for specialized health programs and their partners.
• Deliver timely and accurate results to ensure claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialized health programs, and vendors.
• Collaborate in the creation and implementation of standardized audit workpaper and reporting templates.
• Collect and complete quarterly and annual regulatory filing submissions.
• Serve as a primary contact and liaison for federal claims audit sections related to delegated entities.
• Review and update departmental Policies and Procedures annually, ensuring management approval prior to submission.
• Support the formalization of key internal processes and monitoring tools.
• Complete requests from legal departments and delegation oversight for monitoring and reporting.
• Communicate and collaborate with interdepartmental personnel, leadership, specialized health programs, and partners.
• Collaborate on:
  
  
  
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    The design, implementation, and reporting of special projects.

  • The design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.
  • The assessment, communication, and implementation of regulatory requirements that may impact internal processes.
  
  
  
  
• Apply subject matter expertise in evaluating business operations and processes, identifying areas for technical solutions to improve performance.
• Consult across business operations, providing mentorship, and contributing specialized knowledge.
• Ensure accuracy of facts and details for project/program deliverables to meet departmental, organizational, and legislative policies, standards, and best practices.
• Provide training, recommend process improvements, and mentor junior-level staff and interns as needed.

Must-Have:

• Bachelor's Degree in Accounting, Finance, or a related field, OR equivalent education and/or experience.
• Minimum 5 years of experience performing claims audits or claims processing related to managed care product lines, including state and federal health programs.
• Demonstrated background in managed care, healthcare, or health insurance.
• Proven experience in healthcare claims audit and financial compliance.
• Excellent analytical and critical thinking skills.
• Action-oriented, self-starter, and excellent motivator.
• Excellent verbal and written communication skills.
• Ability to prioritize assignments and work independently with minimal supervision.
• Ability to interface professionally with both internal and external customers at all levels of the organization.
• Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).

Nice-to-Have:

• Expert knowledge of medical claims processes, including state and federal health programs.

• Aquent Talent connects the best talent in marketing, creative, and design with the world's biggest brands.
• Eligible talent get access to amazing benefits such as:
  
  
  
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    Subsidized health, vision, and dental plans

  • Paid sick leave
  • Retirement plans with a match
  
  
  
  
• Aquent is an equal-opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.
• We're about creating an inclusive environment-one where different backgrounds, experiences, and perspectives are valued, and everyone can contribute, grow their careers, and thrive.

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