Senior Audit Analyst, Provider Onboarding

Delta Dental•Alpharetta, GA

44d

About The Position

This position is responsible for the overall success of each audit or exam assigned. This includes analyzing and reviewing requested information, advising the business and/or forming responses, proposing different options for resolving issues, interpreting and documenting requirements, conducting meetings as needed (externally and internally), and alerting management of potential issues. Other responsibilities include collaborating with internal customers to ensure the audit/exam responses are accurate, timelines are met, and their internal activities are compliant. This position also acts as a trainer and mentor to other team members, provides strong industry knowledge and understanding of the enterprise's structure, and is a trusted SME for all audit/exam activities. Manages all audits/exams as projects, focusing on audits and exams with added complexity. Establishes tasks, timelines, and deliverables to meet deadlines with dependencies on other departments. Identifies, engages, and collaborates with respective stakeholders throughout each project. Creates and/or provides guidance in the drafting of audit/exam responses that align with current process and materials and may be referenced in the audit/exam, ensuring accurate, defendable, clear, and concise responses. Reviews lower-level team members' responses prior to submission. Analyzes unexpected findings or trends and shares analysis, potential risks, and recommendations with stakeholders to support adherence to compliance standards. Completes Root Cause Analysis for each issue or Corrective Action Plan (CAP). Manages and tracks issue to completion to prevent repeat findings. Provides monthly assessment on adherence to compliance standards, open corrective action plans, and/or performance guarantees. Researches and resolves issues related to outdated information or unclear processes; Proactively creates and/or enhances audit tools to mitigate potential future issues and provides feedback or recommendations to management. Leads cross-functional meetings to update stakeholders on pertinent issue resolutions, process changes and improvements, and/or system enhancements. Acts as a subject matter expert to team members and consults on complex or escalated issues; Trains and mentors lower-level team members on department concepts, practices, procedures, policies, processes and/or issue resolution. Creates and maintains current desk level procedures (DLPs), reporting, training, and audit tools to support the success of audits and exams. Provides guidance on monitoring audit/exam activities in order to meet compliance standards, contractual obligations, and/or performance guarantees with clients and legislative and regulatory bodies; Analyzes policies, procedures, and business process modifications for compliance. Serves as the primary point of contact for delegated credentialing entities, internal Regulatory, Ethics and Compliance partners, external auditors, regulators, examiners, and internal stakeholders, representing the company with professionalism and accuracy. Oversees the review and assessment of the delegated credentialing agreement, credentialing files submitted by delegated entities to ensure compliance with contractual and regulatory requirements prior to delegation (pre-delegated audits) and throughout the contract period (annual delegated audits). Issues and tracks corrective actions related to credentialing audit findings, collaborating with delegated entities and internal partners to ensure timely and effective resolution. Designs and enhances audit tools, dashboards, and reporting mechanisms to proactively identify and mitigate risks associated with delegated credentialing. Monitors and interprets legislative, regulatory, and accreditation changes (e.g., NCQA, CMS, state regulations) related to credentialing delegation to assess potential impacts. Advises leadership on compliance readiness, regulatory trends, and risks specifically related to delegated credentialing.

Requirements

4+ years with Bachelor's degree
5-7+ years of progressive experience in auditing, compliance, or risk management, with prior experience leading audits or exams preferred.
Strong organizational/time management skills and multi-tasking abilities
Detail-oriented with strong analytical and problem-solving skills
Understands process flows and can identify roadblocks and devise solutions to improve processes
Ability to prioritize and manage duties to meet goals and deadlines
Aptitude to learn and develop proficiencies with new concepts, legal requirements, processes, and technology
Effectively able to adapt to change and be comfortable handling risk and uncertainty
Ability to maintain confidentiality when exposed to sensitive information
Effectively able to teach less-senior employees department processes, policies, and concepts
Knowledge of Microsoft Office programs, i.e. Word, Excel, Outlook etc.

Responsibilities

Manages all audits/exams as projects, focusing on audits and exams with added complexity.
Creates and/or provides guidance in the drafting of audit/exam responses that align with current process and materials and may be referenced in the audit/exam, ensuring accurate, defendable, clear, and concise responses.
Analyzes unexpected findings or trends and shares analysis, potential risks, and recommendations with stakeholders to support adherence to compliance standards.
Completes Root Cause Analysis for each issue or Corrective Action Plan (CAP).
Provides monthly assessment on adherence to compliance standards, open corrective action plans, and/or performance guarantees.
Researches and resolves issues related to outdated information or unclear processes; Proactively creates and/or enhances audit tools to mitigate potential future issues and provides feedback or recommendations to management.
Leads cross-functional meetings to update stakeholders on pertinent issue resolutions, process changes and improvements, and/or system enhancements.
Acts as a subject matter expert to team members and consults on complex or escalated issues; Trains and mentors lower-level team members on department concepts, practices, procedures, policies, processes and/or issue resolution.
Creates and maintains current desk level procedures (DLPs), reporting, training, and audit tools to support the success of audits and exams.
Provides guidance on monitoring audit/exam activities in order to meet compliance standards, contractual obligations, and/or performance guarantees with clients and legislative and regulatory bodies; Analyzes policies, procedures, and business process modifications for compliance.
Serves as the primary point of contact for delegated credentialing entities, internal Regulatory, Ethics and Compliance partners, external auditors, regulators, examiners, and internal stakeholders, representing the company with professionalism and accuracy.
Oversees the review and assessment of the delegated credentialing agreement, credentialing files submitted by delegated entities to ensure compliance with contractual and regulatory requirements prior to delegation (pre-delegated audits) and throughout the contract period (annual delegated audits).
Issues and tracks corrective actions related to credentialing audit findings, collaborating with delegated entities and internal partners to ensure timely and effective resolution.
Designs and enhances audit tools, dashboards, and reporting mechanisms to proactively identify and mitigate risks associated with delegated credentialing.
Monitors and interprets legislative, regulatory, and accreditation changes (e.g., NCQA, CMS, state regulations) related to credentialing delegation to assess potential impacts. Advises leadership on compliance readiness, regulatory trends, and risks specifically related to delegated credentialing.