Grievance & Appeals Auditor I — Compliance & QA

Solis-Health-Plans; Florida; On-site; USD 55,000 - 65,000; Full time

Job summary

Solis-Health-Plans in Doral, FL is seeking a Grievance & Appeals Auditor I to perform end-to-end audits of appeals and grievance cases, ensuring CMS and internal policy compliance.

The role emphasizes accuracy, timeliness, and risk mitigation, with responsibilities including review of eligibility, medical necessity, and documentation, and the preparation of detailed audit reports.

Qualifications

• Auditing skills to review and assess cases accurately.
• Knowledge of CMS regulations and internal policies.
• Ability to document findings clearly and concisely.
• Ability to identify compliance gaps and risk areas.
• Strong attention to regulatory timeframes and deadlines.

Responsibilities

• Conduct pre- and post-resolution audits of member appeals and grievance cases across Medicare Advantage.
• Ensure CMS Medicare Advantage Appeals and Grievance regulations, internal policies, and regulatory timeframes are followed.
• Review case files for accuracy and completeness, including eligibility, coverage, medical necessity, and documentation.
• Validate that appropriate review levels were applied throughout the appeals/grievance lifecycle.
• Document audit findings with clear rationale, regulatory citations, and impact assessments.
• Support audit readiness and regulatory examination activities.
• Prepare detailed audit reports outlining findings, deviations, and risk exposure.

Skills

Auditing

Regulatory compliance

CMS regulations

Documentation

Risk assessment

Job description

Solis-Health-Plans in Doral, FL is seeking a Grievance & Appeals Auditor I to perform end-to-end audits of appeals and grievance cases, ensuring CMS and internal policy compliance.

The role emphasizes accuracy, timeliness, and risk mitigation, with responsibilities including review of eligibility, medical necessity, and documentation, and the preparation of detailed audit reports.