Delegation Oversight Program Claims Auditor - 248753

Delegation Oversight Program Claims Auditor (Fully Remote) Location:

Remote (PST business hours) Schedule:

Monday–Friday | 8:00 AM – 5:00 PM PST Salary Range:

$80,000–$90,000 annually Employment Type:

Full-Time

About the Role We are seeking an experienced Delegation Oversight Program Claims Auditor to support auditing and performance monitoring of delegated entities managing claims functions for a regulated managed care health plan. This role operates on the health plan side, ensuring delegated partners meet contractual, regulatory, and quality standards. This is a fully remote position with strong internal growth opportunities, collaborative leadership, and excellent benefits. Key Responsibilities Conduct pre-delegation and annual audits of delegated entities, including risk assessments and compliance reviews Audit delegated claims operations for accuracy, timeliness, regulatory adherence, and documentation against established standards Monitor delegate performance metrics such as denial rates, turnaround times, and complaint trends Maintain audit tools, workflows, and compliance documentation aligned with health plan and regulatory standards Identify deficiencies and partner with delegates to develop and implement Corrective Action Plans (CAPs) Prepare audit reports and performance summaries for internal leadership and oversight committees Serve as a subject matter expert and liaison, providing regulatory guidance and performance feedback Coordinate cross-functional meetings with operations, quality, and utilization management teams Support audit readiness and external reviews related to accreditation or regulatory compliance Note: This role audits the delegate’s work; it does not involve processing claims.

Required Qualifications High school diploma or GED 3–5+ years of experience in Delegation Oversight within a managed care or health plan environment Health plan audit experience in a delegated model Background in claims auditing, utilization management, or managed care compliance Working knowledge of NCQA, CMS, Medicaid, Medi-Cal, Knox-Keene, and DMHC standards Strong analytical, auditing, and written communication skills Proficiency with Microsoft Office and audit tracking tools

Preferred Qualifications Bachelor’s degree in Healthcare Administration, Health Services, or a related field

Why Join Us Fully remote role with PST hours Strong promote-from-within culture and supportive leadership Positive team environment with high morale Excellent benefits, including 100% company-paid HMO coverage for employees Generous PTO Stable, growing organization