COMPLIANCE INVESTIGATOR/AUDITOR

Healthcare Management Solutions LLC • Fairmont, WV

2d

About The Position

Federal Government Healthcare oversight programs are designed to help ensure compliance with Health Insurance Marketplace requirements for agents, brokers, and enhanced direct enrollment platform entities that assist consumers with obtaining health coverage. The work focuses on evaluating adherence to applicable regulations, consumer protection standards, and operational requirements through compliance reviews and oversight activities. This role is part of the Compliance Investigators/Auditor’s job family and may be filled at Auditor 1, Auditor 2, or Auditor 3 level. Candidate will be selected at a level commensurate with their education, experience, and demonstrated competencies. We are seeking Compliance Investigators/Auditors to support federal oversight activities related to Health Insurance Marketplace operations. This role involves reviewing documentation, conducting audits and investigations, analyzing data and operational practices, assessing compliance with federal requirements, and documenting findings. This position is well suited for professionals with experience in auditing, investigations, compliance, healthcare, insurance, or regulatory oversight.

Requirements

• Knowledge of health insurance, Marketplace operations, agents and brokers, or direct enrollment platforms.
• Experience reviewing and analyzing large volumes of documentation and data.
• Skills in report writing, evidence collection, and case documentation.
• Experience conducting audits and compliance reviews while maintaining confidentiality and professionalism.
• Ability to organize, prioritize, and manage multiple tasks and deadlines in a fast-paced environment.
• Bachelor's Degree (Healthcare industry related is preferred).
• Equivalent combination of education and experience may be acceptable.
• 2 years’ experience with internal/external auditing.
• Experience with or knowledge of agent and broker oversight activities, including compliance monitoring, documentation reviews, investigations, corrective actions, and enforcement processes.
• Familiarity with Direct Enrollment (DE) and Enhanced Direct Enrollment (EDE) models and the operational, technical, and compliance requirements associated with these entities.
• Knowledge of onboarding, monitoring, and oversight processes for web-brokers, direct enrollment entities, or other consumer-facing enrollment partners.
• 5 years’ experience with internal/external auditing.
• 2 years of experience in a related field, such as Health Insurance Marketplace operations, health care auditing, or federal regulatory oversight.
• 5 years of experience in a related field, such as Health Insurance Marketplace operations, health care auditing, or federal regulatory oversight.

Nice To Haves

• Experience in the health insurance sector, specifically related to health care compliance, health care regulations, or health care auditing.
• Certified internal/external auditor (CIA) a plus.
• Insurance Regulatory Examiners Society (IRES) professional designation (MCM, AIE) is a plus.

Responsibilities

• Review policies, procedures, consumer-facing materials, records, and supporting documentation to evaluate compliance risks and operational effectiveness.
• Analyze audit evidence, research findings, and data from multiple sources to identify trends, anomalies, and potential compliance concerns.
• Document audit findings, prepare workpapers, and develop clear reports summarizing observations, risks, and recommendations.
• Monitor corrective actions and assess whether identified compliance issues have been appropriately resolved.
• Support compliance reviews, monitoring activities, complaint referrals, and oversight activities related to enrollment practices, marketing activities, and operational compliance.
• Collaborate with subject matter experts and government stakeholders to support compliance and enforcement initiatives.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level