Senior Compliance Examiner/Auditor – MLR exams

Examination Resources, LLC; Northern (KY); Hybrid; USD 75,000 - 110,000; Full time

Job summary

Examination Resources, LLC is seeking a Senior Compliance Examiner/Auditor to support comprehensive Medical Loss Ratio (MLR) examinations. The role involves analyzing MLR calculations, rebate distributions, and QA testing of premium and claims data, with emphasis on regulatory compliance under CCIIO/HHS ACA frameworks.

Experience in auditing or accounting within healthcare insurance is highly valued. The position is remote, with no travel, and requires strong analytical, interpersonal, and

Qualifications

• Experience with MLR or healthcare insurance auditing or accounting is required.
• Bachelor's Degree in Accounting or Finance is preferred, but not required.
• Minimum 2+ years’ experience as an accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, insurance company, or other entity involved in MLR audits.
• CPA, CIA, CFE, and/or AFE certifications are preferred but not required.
• Proficient in presenting, spreadsheets, and project planning software such as TeamMate, ACL/Access/Tableau, MS Excel, Word and PowerPoint.

Responsibilities

• Perform analytical reviews of documentation supporting MLR calculations and rebate distributions for compliance with state/federal laws.
• Test accuracy of premium and claims transactions and other major MLR components.
• Review QIA expenses to ensure costs meet definitions and intercompany allocations are fair.
• Review PBM contracts and prescription data for regulatory compliance.
• Interpret MLR regulations and guidance against provided documentation.
• Draft or supervise clear written conclusions on MLR procedures.
• Assist and contribute to internal MLR trainings and audit procedures.

Skills

Auditing

Accounting

MLR compliance

Healthcare insurance auditing

Analytical skills

Interpersonal skills

Time management

Communication skills

Examination/audit

Education

Bachelor's Degree in Accounting or Finance

CPA

CIA

CFE

AFE

Tools

TeamMate

ACL/Access

Tableau

MS Excel

MS Word

PowerPoint

Job description

Senior Compliance Examiner/Auditor – MLR exams

Job Description

Senior Compliance Examiner

Position Overview

The Senior Compliance Examiner/Auditor will assist in completing comprehensive Medical Loss Ratio (MLR) examinations in accordance with the procedures developed by the Center for Consumer Information and Insurance Oversight (CCIIO ), a division of the Department of Health and Human Services (HHS) responsible for implementation of the Affordable Care Act (ACA). MLR Examinations may also be performed on behalf of various state insurance departments.

Experience with auditing or accounting highly desired. Experience with MLR and related rebate requirements, or accounting/auditing in the healthcare, insurance , banking and/or Pharmacy Benefit Management (PBM ) industries required. All work is expected to be completed remotely; no travel required.

Specific Duties and Responsibilities

• Perform analytical reviews of documentation provided by companies supporting MLR calculations and distribution of rebates to enrollees for compliance with state and/or federal legislation.
• Perform attribute and accuracy testing of premium and claims transactions, and other major components of the MLR calculation to determine completeness and accuracy.
• Review Quality Improvement Activity (QIA) expenses, which are costs for activities that improve the quality of care provided to members, ensuring reported costs meet the definition of QIA and that intercompany allocations are fair and reasonable.
• Review Pharmacy Benefit Manager contracts and detailed prescription drug claims data for compliance with applicable state laws and regulations.
• Interpret MLR regulations, filing instructions and technical guidance in comparison to documentation provided by companies.
• Write and/or supervise others in the written documentation of clear, concise, and informative conclusions on required MLR examination procedures.
• Assist and lead in the creation of internal MLR trainings and audit procedure creation.

Requirements

• Experience with MLR or healthcare insurance auditing or accounting required.
• Bachelor's Degree in Accounting or Finance is preferred, but not required.
• Minimum 2+ years’ experience as an accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, insurance company, or other entity involved in conducted MLR related audits.
• CPA, Certified Internal Auditor (CIA), Certified Financial Examiner (CFE), and/or Accredited Financial Examiner (AFE) preferred, but not required.
• PC skills, including experience in using software for producing presentations, spreadsheets, and project planning (skilled in TeamMate, ACL/Access/Tableau, and MS Excel, Word and PowerPoint).
• Strong interpersonal, presentation, analytical and examination/audit skills .
• Excellent organizational skills and the ability to prioritize multiple tasks, projects and assignments using effective time management skills.
• Strong written and verbal communication skills.
• Dynamic/flexible demeanor with exceptional customer service skills.
• Must be self-motivated, work well independently and possess a sense of urgency.
• Ability to demonstrate ethical and professional standards as outlined by the Firm.