Lead Audit Specialist - Remote

EmblemHealth; New York (NY); Remote; USD 78,000 - 149,000; Full time

Job summary

EmblemHealth in New York seeks a Senior Audit Lead to guide all external regulatory audits for Medicare Advantage, Part D, and state programs. You will plan, oversee data collection, and coordinate with regulators, internal SMEs, and cross-functional teams to deliver timely, accurate results.

The role requires 5–8+ years in healthcare audits, strong leadership, and excellent communication skills. Occasional travel to EmblemHealth facilities may be required, with a focus on minimizing business

Qualifications

• Bachelor’s Degree in a relevant field.
• 5–8+ years of professional work experience (Required).
• Healthcare industry experience with government audits (Required).
• Extensive knowledge of Medicare Advantage/Part D audits; HCC validation (Required).
• Experience managing external audit activities for CMS, HHS OIG, NYS agencies (Required).
• Excellent communication, leadership, and cross-functional collaboration skills (Required).

Responsibilities

• Lead and coordinate all phases of external regulatory audits.
• Plan, manage, and execute RADV and Part C&D audits.
• Coordinate regulators, internal SMEs, and cross-functional teams.
• Ensure timely remediation and minimal business disruption.
• Provide audit monitoring reports to CMS and leadership.
• Collaborate with Enrollment, Provider Operations, and related teams.
• Oversee vendor relationships and contract compliance.

Skills

Audit management

Regulatory compliance

Regulatory audits

Strong communication

Leadership

Education

Bachelor’s Degree

Tools

Microsoft Office

Job description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

Need Assistance Applying? EmblemHealth provides reasonable accommodations to individuals with disabilities throughout the application and hiring process. If you need an accommodation, please contact [e-mail] so we can support your request in accordance with applicable law.

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Lead and coordinate all phases of external regulatory audits across Medicare Advantage, Medicare Part D, State Sponsored Products, and Commercial (on and off exchange) plan products, ensuring timely and accurate audit data responses and submissions. Plan, manage, and execute RADV audits, including data analysis to identify required medical records, vendor oversight, project management, and submission of medical records, supporting documents, and data files to CMS. Lead and coordinate Part C & D Data Validation audits, including stakeholder communication, data collection, quality review, aggregation, and submission of supporting documentation. Provide operational and regulatory guidance to audit stakeholders to prepare for audits, minimize audit risk, and protect the organization from adverse financial impacts related to risk adjustment audits. Manage vendor relationships and contracts to ensure audit vendors execute in accordance with contractual language, follow best practices and produce accurate and compliant results. Collaborate with regulators, internal SMEs, and cross-functional departments to gather, organize, and deliver required documentation to auditors. Coordinate organizational responses to audit findings and facilitate timely remediation or corrective action as needed. Ensure overall audit success by delivering required information accurately and on schedule with minimum disruption to operational areas.

• Manage the coordination of CMS MA contract level RADV Audits, HHS ACA IVA Audits, including HCC validation, Demographic and Enrollment (D&E) validation and Pharmacy Claims(“RXC”) validation for all EHHIOS IDs.
• Manage external Medicare, State Sponsored and commercial product-related audit efforts, including audits from CMS and its audit contractors/consultants, HHS, OIG, NYS DOH, NYS OMIG, NYS Dept of Finance and NYS Office of the State Comptroller.
• Coordinate the efforts of multiple departments that support our response to these audits.
• Lead the full audit lifecycle, including announcements, entrance/exit conferences, onsite activities, documentation, delivery of findings, corrective action plan (CAP) collection and tracking, and submission of required monitoring reports to regulatory agencies.
• Coordinate and organize remote and/or onsite audit activities for live audits by serving as the primary liaison to external auditors, managing onsite and/or remote interview sessions, documenting meeting minutes, and maintaining audit follow-ups.
• Manage audit documentation and deliverable requests, including gathering data, universes, policies, sample materials, and other evidence from internal departments; ensure timely, secure delivery to auditors and maintain a complete internal archive of deliverables and communications.
• Ensure regulatory audits for Medicare, State Sponsored Programs, and Commercial products are conducted efficiently with minimal business disruption; recommend and implement process improvements to streamline audit and compliance operations.
• Provide routine audit monitoring reports to CMS and internal leadership as necessary; conduct trend analysis, offer audit planning recommendations, and develop processes to strengthen regulatory compliance and audit readiness.
• Support and coordinate CMS Part C & Part D IPM, CMS Contract-Level RADV, and HHS IVA RADV audits, OIG audits including managing medical record retrieval, validating claims/encounter/provider data, and tracking all RADV deliverables.
• Develop and refine RADV audit strategies, including improvements in medical record retrieval processes and reducing coding errors; manage efforts to enhance RADV audit coordination workflows.
• Collaborate with internal teams (including, but not limited to Enrollment, Provider Operations, Provider Relations, Network Management, Relationship Managers) to ensure providers, facilities, delegates, and vendors supply required information for all annual government audits as referred to above. Implement HHS mandated IVA process changes.
• Work with the Medicare Compliance and External Audit Leader on process improvement initiatives.
• Compile data and information to support monitoring and dashboard status reporting Senior Management.
• Support other Compliance Department activities as directed, assigned, or required.
• Support organizational initiatives and projects.

Qualifications

• Bachelor’s Degree
• 5 – 8+ years’ relevant, professional work experience (Required)
• Experience in healthcare industry – performing/participating in government audits (Required)
• Extensive knowledge of Medicare Advantage and Medicare Prescription Drug Programs; CMS Contract Level RADVs, HHS ACA IVA audits; including HCC validation, Demographic & Enrollment (D&E) validation, and Pharmacy Claims (RXC) validation across all applicable HIOS IDs. (Required)
• Experience managing external audit activities for Medicare, State Sponsored, and commercial product lines, including audits conducted by CMS and its contractors, HHS OIG, NYS DOH, NYS OMIG, NYS Department of Financial Services, and the NYS Office of the State Comptroller; familiarity with regulators’ audit processes and requirements (Required)
• Working knowledge of health insurance operations - understanding of Commercial health insurance, enrollment, and Individual and Small Group coverage, etc. (Required)
• Additional experience/specialized training may be considered in lieu of educational requirement (Required)
• Proficiency in the use of Microsoft Office - Word, Excel, Access, PowerPoint, Outlook, Teams, etc. (Required)
• Ability to organize, prioritize, and successfully manage multiple tasks/projects with simultaneous competing deadlines (Required)
• Strong analytical and problem-solving skills; and outstanding attention to details (Required)
• Must be a leader and consensus-builder, able to successfully negotiate with Department heads for the timely delivery of audit data and documents (Required)
• Must be a team player willing to assist, and correctly advise, operational areas on successful completion of audits, submission of audit deliverables and compliance with regulations (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
• Ability to arrange work schedule to meet deadlines from multiple sources and engage staff throughout EmblemHealth to assist in the completion of duties and to travel to all EmblemHealth facilities as needed (Required)
• Ability to advise Senior Management on regulatory reporting and audit trends and tactics, as well as EmblemHealth’s audit vulnerabilities and risks.

Additional Information

• Requisition ID: 1000003441
• Hiring Range: $77,760-$149,040

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third‑party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.