Auditor

• Conduct detailed reviews of Medicaid and CHIP eligibility determinations to ensure compliance with federal and state regulations
• Evaluate eligibility determinations related to applications, renewals, post-Public Health Emergency (PHE) unwinding activities, and subsequent regulatory updates
• Apply clinical judgment to cases involving disability criteria, functional limitations, medical necessity, long-term care pathways, or medically complex eligibility scenarios
• Assess state Medicaid eligibility policies, procedures, and operational workflows for consistency with regulatory and clinical requirements
• Identify and analyze vulnerabilities, risks, or non-compliance issues, including those with clinical implications
• Review and interpret medical records, disability assessments, functional evaluations, and other clinical and administrative documentation
• Use data analytics and case review insights to identify trends, patterns, and high-risk areas for deeper clinical or eligibility analysis
• Prepare or contribute to comprehensive audit reports summarizing findings, root causes, clinical considerations, and corrective actions for CMS/CPI and CMCS
• Produce clear, well-documented evidence to support audit conclusions and clinical determinations
• Serve as a clinical subject-matter expert (SME), advising the audit team on medically complex or ambiguous eligibility cases
• Collaborate with state agencies to obtain documentation, clarify processes, and understand clinical elements of eligibility decisions
• Participate in coordination meetings to ensure alignment across clinical and eligibility review activities
• Stay current on federal and state Medicaid eligibility pathways, clinical criteria, and regulatory guidance
• Assist in developing and refining audit tools, templates, and methodologies to incorporate clinical considerations
• Support quality assurance efforts by verifying the accuracy and validity of clinical and regulatory findings before submission
• Mentor and support junior auditors and team members as needed
• Contribute to ongoing improvement of audit protocols, processes, and training materials
• Effectively manage workload, timelines, and documentation requirements in a fully remote environment

Clinical Eligibility Auditor

IT Auditor

Auditor III

Eligibility Staff Auditor

Senior IT Internal Auditor