Summary of Job

Lead and coordinate all phases of external regulatory audits across Medicare Advantage, Medicare Part D, Medicaid Managed Care (including Child Health Plus), and Commercial (on and off exchange) plan products, ensuring timely and accurate data submissions. Plan, manage, and provide oversight for RADV audits, including data analysis to identify required medical records, vendor oversight, project management, and submission of medical records, supporting documents, and data files. Lead and coordinate Part C & D Data Validation audits, including stakeholder communication, data collection and quality review, aggregation, and submission of supporting documentation. Provide operational and regulatory guidance to prepare for audits, minimize audit risk, and protect the organization from adverse financial impacts related to risk adjustment. Manage vendor relationships and contracts to ensure audit vendors follow best practices and support accurate, compliant risk adjustment and enrollment revenue. 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.

Responsibilities

• Manage the coordination of HHS ACA RADV IVA Audits, CMS MA contract level RADV Audits, and Commercial on/off exchange products, including HCC validation, Demographic and Enrollment (D&E) validation and Pharmacy Claims ("RXC") validation for all EH and CCI HIOS IDs, etc.
• Manage external Medicare, Medicaid (including Child Health Plus) 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 audit activities across operational areas; serve as the primary liaison to external auditors, including managing onsite visits, documenting meeting minutes, and maintaining the electronic audit archive.
• Manage end-to-end audit documentation requests, including gathering data, policies, sample materials, and other evidence from internal departments; ensure timely, secure delivery to auditors and maintain a complete archive of deliverables and communications.
• Ensure regulatory audits for Medicare, Medicaid, 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 OIG RADV 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 the annual IVA audit; 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 reports and reporting to Senior Management as required.
• 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.
• Experience in healthcare industry - performing/participating in audits (Required)
• 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 validation, Demographic & Enrollment (D&E) validation, and Pharmacy Claims (RXC) validation across all applicable HIOS IDs (Required)
• Experience managing external audit activities for Medicare, Medicaid (including Child Health Plus), 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 EmblemHealth to assist in the completion of duties and to travel to all EmblemHealth facilities as needed (Required)
• Ability to advise Senior Management on regulatory reporting and audit trends and tactics, as well as EmblemHealth's audit vulnerabilities and risks.