Alignment Health

Auditor – Delegate Credentialing

Alignment Health

full-time

Posted on:

Location Type: Remote

Location: United States

Visit company website

Explore more

✨ AI Apply
Apply

Salary

💰 $70,823 - $106,234 per year

About the role

  • 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.
  • 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.

Requirements

  • 3-5 years of credentialing experience in an HMO, Medicare Advantage, and/or IPA setting
  • 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.
  • 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.
  • Proficient data-entry skills, including 10-key by touch, with a high degree of accuracy.
Benefits
  • Health insurance
  • Retirement plans
  • Paid time off
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
credentialing experienceoversight auditsMedicare Managed CareNCQA requirementsHICE requirementsregulatory compliancedata analysisrisk assessmentCorrective Action Plansaudit documentation
Soft Skills
organizational skillsattention to detailanalytical skillsproblem-solvinginitiativetime managementcommunication skillsinterpersonal skillsconfidentialityrelationship building