Auditor, Delegate Credentialing

Alignment Health•Lincoln, NE

1d•$70,823 - $106,234

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 Credentialing plays an essential role in supporting Alignment Healthcare’s delegated oversight audit program by conducting credentialing audits, validating compliance with regulatory and contractual requirements, and contributing to the organization’s shift toward a more proactive and performance‑focused oversight model. Working under the guidance of the Manager, Audit Administration, the Auditor executes credentialing audits using established methodologies and documentation standards, ensuring audit activities align with the organizational audit strategy and regulatory expectations. In this capacity, the Auditor plans and conducts audits of delegated entities responsible for Medicare Advantage credentialing functions, ensuring adherence to federal, state, and industry credentialing standards. The Auditor also synthesizes findings and supports the development of effective corrective action expectations. Complex or irregular issues are escalated to the Manager, Audit Administration for guidance and resolution. Through diligent audit execution, strong documentation practices, and effective collaboration with internal and external stakeholders, the Auditor strengthens Alignment’s credentialing oversight program and contributes to a critical function that safeguards members’ wellbeing, outcome, and experience.

Requirements

3-5 years of credentialing experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of credentialing aspects of managed care operations.
Prior Medicare Managed Care credentialing 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 NCQA, HICE, or related credentialing requirements.
Required: High school diploma
Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing delegated credentialing 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.
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.

Nice To Haves

Preferred: Bachelor’s degree in a related subject
Preferred: None

Responsibilities

Conduct credentialing audits in accordance with regulatory, contractual, and industry standards
Execute delegated credentialing audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
Evaluate delegated entities’ compliance with CMS, DMHC, NCQA, federal/state credentialing requirements, and Alignment’s contractual standards.
Maintain organized, complete, and audit‑ready documentation to support regulatory reviews, accreditation audits, and internal oversight.
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 understanding credentialing requirements and expectations for corrective actions.
Promote productive and professional working relationships to foster transparency, collaboration, and continuous improvement.
Perform risk assessment and prioritize audits
Assist in identifying high‑risk focus areas by reviewing prior audit results, monitoring data, and operational issues related to credentialing performance.
Recommend audit prioritization based on risk severity, regulatory sensitivity, and emerging compliance trends.
Provide input to refine audit scopes and schedules in alignment with the Manager’s risk‑based audit and monitoring strategy.
Escalate emerging risks or irregular credentialing issues to the Manager, Audit Administration for strategic review and inclusion in future audit planning.
Validate corrective actions for credentialing compliance
Review and validate Corrective Action Plans (CAPs) submitted by delegated entities, ensuring remediation fully addresses identified credentialing deficiencies.
Assess evidence such as updated credentialing files, process changes, workflow revisions, and policy updates to confirm compliance with regulatory and contractual standards.
Track CAP progress and ensure follow‑up activities are completed and documented according to departmental requirements.
Escalate irregular, incomplete, or stalled CAPs to the Manager, Audit Administration to support timely issue resolution.
Report credentialing audit findings to facilitate organizational awareness
Prepare clear, concise, and well‑structured audit summaries highlighting key risks, deficiencies, and improvement opportunities across delegated credentialing practices.
Contribute to department‑standard reporting tools, dashboards, and audit documentation used for leadership 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.
Additional Responsibilities
Manage multiple credentialing audits simultaneously, ensuring adherence to timelines, scope, and quality standards.
Monitor credentialing‑related data to identify emerging trends, potential non‑compliance, and areas requiring targeted review.
Contribute subject‑matter insights during training or education sessions for delegated entities to reinforce credentialing expectations and reduce recurring deficiencies.
Support compilation of documentation and evidence for CMS, NCQA, or other regulatory audits.
Perform additional responsibilities and projects as assigned.