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Overview

Job Summary:

This position is responsible for supporting the organization and clients in meeting Federal and State regulatory requirements through audit readiness, audit management, and corrective action plan (CAP) execution. The role supports compliance initiatives by leading and coordinating internal and external audits, monitoring audit-related regulatory guidance, and managing the lifecycle of corrective action plans tied to Medicare and Medicaid healthcare programs. The role works cross-functionally with key stakeholders such as claims, enrollment, utilization management, risk adjustment, client success, product owners, vendors, and other areas to ensure audit findings are resolved and CAPs are closed in accordance with CMS and state regulatory guidelines.

Key Responsibilities

 

Essential functions may vary depending on the specific focus of the role within the corporate compliance team

• Coordinate and support internal and external audits, including CMS Program Audits, state audits, delegation oversight audits, and client-driven audits.
• Monitor, interpret, and track CMS guidance such as Final Rules, HPMS memos, audit protocols, and Federal Register communications impacting audit and CAP obligations for Medicare Advantage, Medicaid, and other healthcare programs.
• Develop, draft, and manage Corrective Action Plans (CAPs) in response to audit findings, self-identified issues, or regulatory notices, ensuring root cause analysis, remediation steps, and monitoring plans are clearly documented.
• Track CAP milestones, deliverables, and deadlines to ensure timely submission and closure with CMS, state agencies, or clients.
• Communicate audit findings, CAP status, and regulatory requirements to internal and external stakeholders.
• Prepare audit readiness materials, universe pulls, and supporting documentation for regulatory and client audits.
• Oversee and maintain the organization's audit and CAP tracking/distribution process, including centralized logs of open findings and remediation status.
• Partner with internal business and product stakeholders to validate corrective actions and confirm sustained compliance post-remediation.
• Maintain audit and CAP documentation, evidence files, and implementation timelines in accordance with recordkeeping requirements.
• Track resolution of identified compliance risks and escalate unresolved or high-risk findings appropriately.
• Support the development of desk-level procedures, audit playbooks, presentations, and training materials related to audit and CAP processes.

 Qualifications and Requirements:

• Bachelor's degree in healthcare administration, public health or related field.
• Certification in healthcare compliance (CHC) preferred
• Minimum of four (4) years of managed care, healthcare operations, or regulatory compliance. 
• Working knowledge of Medicare, Medicaid, and ACA health plan regulations along with related federal and state laws.
• Experience supporting or leading CMS Program Audits, state audits, or client audits preferred.
• Demonstrated experience developing and managing Corrective Action Plans, including root cause analysis and remediation tracking.
• Strong interpersonal skills and the ability to collaborate with colleagues at all levels.
• Excellent analytical, organizational, and communication skills, with strong attention to detail.
• Ability to prioritize and manage multiple cross-functional audit and CAP priorities simultaneously.
• Proficiency in Microsoft Excel, Word, PowerPoint, and audit/CAP tracking or case management tools.

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

FLSA Classification (USA Only): Exempt 

Work Environment: 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: 

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

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**The annual US base salary range for this position is $75,000 to $95,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education. 

Employment Type: FULL_TIME