Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Remote The Auditor, Delegate Determinations, Appeals, and Grievances (ODAG) plays a critical role in supporting Alignment Healthcare’s delegation oversight program by assessing, validating, and strengthening the accuracy, completeness, and CMS audit readiness of delegated entities’ ODAG data submissions. The role is primarily responsible for auditing ODAG universe data, record layouts, and supporting documentation to ensure delegated partners meet CMS regulatory requirements, contractual obligations, and enterprise data integrity standards.
Working under the guidance of the Senior Manager, Audit Administration, who defines the overall audit strategy and oversight framework, the Auditor performs detailed data focused audits of ODAG universes, evaluates data lineage and system controls, and verifies that delegated entities’ submissions accurately reflect operational activity. The Auditor applies CMS ODAG audit protocols, record layout specifications, and timeliness requirements to identify gaps, inconsistencies, or systemic risks that could impact regulatory audit outcomes.
In this capacity, the Auditor collaborates closely with cross functional partners, including Delegate Performance, Compliance, UM, Claims, and Operational Intelligence, to ensure ODAG data is reliable, defensible, and audit ready. The role translates technical data findings into clear, actionable insights to support remediation, performance improvement, and sustained compliance.
The Auditor also maintains productive working relationships with delegated provider organizations by guiding them through data validation expectations, audit readiness requirements, and corrective action development. The role supports delegates in strengthening internal controls, documentation practices, and monitoring processes related to ODAG data reporting. Complex data integrity issues, repeat deficiencies, or high risk findings are escalated to the Manager to ensure alignment with the broader oversight, risk mitigation, and regulatory preparedness strategy.
Job Duties/Responsibilities:
Conduct ODAG Data Quality and Audit Readiness Reviews
- Execute detailed audits of delegated entities’ ODAG universe submissions to assess accuracy, completeness, timeliness, and compliance with CMS ODAG Program Audit Protocols and record layout specifications.
- Perform universe integrity testing across all applicable ODAG universe tables, validating data elements against source systems, operational workflows, and supporting documentation.
- Review data lineage, system controls, and processing logic to confirm ODAG data accurately reflects operational activity and regulatory requirements.
- Identify data discrepancies, misclassifications, timeliness failures, and systemic issues that may pose CMS audit risk.
- Maintain organized, audit‑ready workpapers and documentation to support internal oversight, compliance reviews, and regulatory audits.
Support CMS ODAG Audit Preparedness
- Apply CMS ODAG audit standards, universe submission requirements, and timeliness criteria to evaluate delegated entities’ readiness for regulatory audits.
- Assist in preparation for CMS ODAG audits by validating universe submissions, reviewing sample cases, and confirming availability and quality of supporting documentation.
- Support internal and external audit activities by compiling evidence, responding to data validation inquiries, and assisting with universe resubmissions when required.
- Identify and escalate high‑risk data integrity issues that could result in audit findings, corrective actions, or enforcement actions.
Engage Delegated Entities to Improve Data Quality
- Communicate audit scope, data validation expectations, findings, and remediation requirements clearly and professionally to delegated provider organizations.
- Provide delegates with clear explanations of data errors, root causes, and regulatory implications related to ODAG reporting.
- Guide delegated entities in developing and implementing corrective actions to address data quality, documentation, and process gaps.
- Promote collaborative, transparent working relationships to strengthen delegated oversight effectiveness and sustained compliance.
Validate Corrective Actions and Ongoing Compliance
- Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation adequately addresses identified ODAG data deficiencies.
- Evaluate supporting evidence, including system updates, workflow changes, and documentation enhancements, to confirm corrective actions are effective and sustainable.
- Track CAP progress, follow‑up activities, and closure to ensure timely and complete resolution.
- Escalate incomplete, ineffective, or recurring issues to the Manager, Audit Administration, for further oversight and intervention.
Perform Risk Assessment and Reporting
- Analyze historical audit results, monitoring reports, and performance trends to identify emerging ODAG data risks and prioritize audit focus areas.
- Contribute to risk‑based audit planning by providing insights into recurring data issues, systemic weaknesses, and delegate performance patterns.
- Prepare clear, concise audit summaries and reports highlighting key findings, trends, risks, and improvement opportunities.
- Aggregate audit results into standardized reporting formats for leadership review and cross‑functional communication.
Additional Responsibilities
- Manage multiple audits and data validation projects concurrently while meeting established timelines and quality standards.
- Monitor ongoing ODAG data submissions and performance metrics to proactively identify potential non‑compliance.
- Assist with special projects, regulatory requests, and enterprise initiatives related to delegation oversight and data integrity.
- Perform other duties as assigned in support of the delegation oversight and audit administration functions.
Job Requirements:
Experience:
- Minimum 7 years of claims experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of claims aspects of managed care operations.
- Prior Medicare Managed Care ODAG experience related to delegation oversight and auditing.
- Minimum 5 years experience conducting oversight audits of delegated entities and/or ancillary providers
- Demonstrable detailed knowledge/experience with CMS reporting – Part C, ODAG, Monthly Timeliness, etc.
Education:
• Required: High school diploma
• Preferred: Bachelor’s degree in a related subject
Training:
• Required: None
• Preferred: None
Specialized Skills:
• Required:
- Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing delegated claims 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.
- Working knowledge of medical terminology, claims processing systems, and claims coding structures (CPT, RVS, ICD‑10, HCPCS).
- Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence.
- Proficient data‑entry skills, including 10‑key by touch, with a high degree of accuracy.
- Solid understanding of state and federal claims processing requirements and managed‑care operational frameworks.
Licensure:
• Required: None
Other:
• Required: None
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $70,823.00 - $106,234.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.
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