Auditor, Delegate Claims

Alignment Health•Lincoln, NE

About The Position

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. The Auditor, Delegate Claims, plays a critical role in supporting Alignment Healthcare’s delegated oversight audit program by executing claims related audits, validating compliance with regulatory and contractual requirements, and contributing to the organization’s 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 partners—including Delegate Performance, internal claims, quality, and compliance—to 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.

Requirements

3-5 years of claims experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of claims aspects of managed care operations.
Prior Medicare Managed Care claims experience related to delegation oversight and auditing.
1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers
Demonstrable detailed knowledge/experience with CMS claims compliance reporting – Part C, ODAG, Monthly Timeliness, etc.
High school diploma
Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing delegated claims operations.
Exceptional organizational skills with the ability to maintain accurate, complete, and audit‑ready documentation across multiple concurrent workstreams.
High attention to detail with strong analytical and problem‑solving capabilities to evaluate data, identify patterns, and determine root causes of issues.
Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight.
Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally.
Ability to maintain confidentiality and comply with HIPAA and all other privacy and data‑security standards.
Strong interpersonal skills and the ability to build positive, productive working relationships with co‑workers, internal stakeholders, delegated entities, and external partners.
Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work.
Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook, and the ability to use these tools to analyze data, document audit findings, and support reporting needs.
Working knowledge of medical terminology, claims processing systems, and claims coding structures (CPT, RVS, ICD‑10, HCPCS).
Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence.
Proficient data‑entry skills, including 10‑key by touch, with a high degree of accuracy.
Solid understanding of state and federal claims processing requirements and managed‑care operational frameworks.

Nice To Haves

Bachelor’s degree in a related subject

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 entities’ compliance with CMS and contractual requirements related to claims processing and adjudication.
Maintain organized, audit‑ready 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 problem‑solving and strengthen oversight effectiveness.
Perform risk assessment and prioritize audits
Contribute to identifying high‑risk 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 follow‑up 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 department‑standard reporting formats for leadership review and cross-functional communication.
Partner with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal teams to ensure findings are understood and actionable.
Support preparation of materials for internal committees, regulatory bodies, and enterprise risk‑management forums.
Manage multiple audits and related projects simultaneously, ensuring adherence to timelines, scope, and quality standards.
Monitor and analyze reported data to identify potential non-compliance and initiate corrective action plans when needed.
Contribute subject‑matter expertise during education sessions for delegated entities to address non-compliance trends and reinforce expectations.
Assist in preparing documents and evidence for CMS or other regulatory audits as required.
Perform other projects and duties as assigned.