Delegation Oversight Auditor

Community Health Plan of Imperial Valley•Imperial, CA

12d

About The Position

Community Health Plan of Imperial Valley (CHPIV) is a local health plan committed to improving community health and well-being by providing accessible, high-quality, culturally sensitive healthcare through education, outreach, and innovative care. The Delegation Oversight Auditor supports this mission by ensuring administrative and non-clinical functions performed by delegated entities comply with regulatory, contractual, and clinical standards. The role evaluates process compliance and operational workflows across internal and delegated functions; conducts audits of non-clinical delegated functions; validates the accuracy, completeness, and timeliness of delegate-submitted materials; and assesses compliance with applicable regulatory requirements and contractual obligations. The auditor identifies operational and documentation gaps, contributes to corrective action planning, monitors corrective action plans, and supports verification studies and external audit readiness. The position collaborates with internal departments and external delegates to promote alignment and operational consistency.

Requirements

Bachelor’s degree in Healthcare Administration, Public Health, Business, or a related field; equivalent experience may be considered in lieu of a degree.
Minimum of 3–4 years of experience in compliance, auditing, or regulatory oversight within a managed care or healthcare delivery environment.
Familiarity with Medi-Cal and/or Medicare regulatory requirements, including DHCS, DMHC, and CMS.
Strong understanding of delegated functions such as claims, encounters, credentialing, and language assistance services.
Ability to review and interpret policies, procedures, and operational workflows.
Excellent organizational, analytical, and time management skills, with the ability to manage multiple priorities.
Strong written and verbal communication skills, including the ability to draft audit findings and compliance reports.
Proficiency in Microsoft Office, including Excel, Word, Outlook, and PowerPoint.
Experience working with audit tracking systems or similar tools.
Ability to work independently and collaboratively in a fast-paced, deadline-driven environment.

Responsibilities

Evaluate process compliance and operational workflows for internal and delegated functions.
Identify systemic issues and contribute to corrective action planning.
Monitor regulatory metrics and reporting to committees.
Conduct audits of non-clinical delegated functions, including claims, encounters, credentialing, language assistance services, and program effectiveness.
Review and validate the accuracy, completeness, and timeliness of delegate-submitted reports, logs, and materials.
Assess compliance with DHCS, DMHC, CMS, and NCQA regulatory requirements and contractual obligations.
Identify documentation, workflow, and performance gaps that could result in audit findings or compliance risks.
Monitor corrective action plans and validate resolution of findings to ensure sustained compliance.
Support enterprise-wide verification studies and external audit readiness, including pre-audit documentation review and file validation.
Collaborate with internal departments and external delegates to ensure alignment and operational consistency.