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. The target hiring compensation range for this role is $63.00hr to $66.00hr. Compensation is based on several factors, including, but not limited to, education, relevant work experience, relevant certifications, and location.

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