Compliance Claims Audit Manager

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 410k plan. Additional employee paid coverage options available.

Job purpose

The Compliance Claims Audit Manager is responsible for leading and managing the claims compliance audit program for All Care To You (ACTY). This role oversees the delegated claims audit process from start to finish, ensuring all audit deliverables are completed accurately, thoroughly, and on time.

The Compliance Claims Audit Manager ensures that all audits are conducted with the highest standards of quality and integrity, identifies and monitors corrective actions for compliance-related findings, and collaborates across teams to promote continuous improvement. This position plays a key role in maintaining ACTY’s audit readiness and strengthening the organization’s overall regulatory compliance posture.

Duties and responsibilities

• Develop, implement, and maintain audit schedules, methodologies, and tools for health plan–initiated claims audits.

• Responsible for overseeing claims compliance audits including but not limited to:
  • Delegating file preparation to the Compliance Coordinators
  • Ensuring all claims audit file preparation documentation is requested from various departments (Claims, Contracting, Configuration, Finance, etc).
  • Reviewing files for inconsistencies, quality assurance, and proactive identification of errors and remediation response within the file packet
  • Ensures all audit deliverables are submitted in their entirety and timely.
  • Initial work up of the claims audit related questionnaires
  • Sends audit related questionnaires and attestations to Claims leadership for final review and approval prior to submission to ensure cross department alignment
  • Coordinates with Compliance Officer, Compliance Director, and other department heads on audit results and Corrective Action Plans as applicable.

• • Lead the preparation and coordination of health plan oversight audits, including pre-audit readiness (questionnaires), document collection, and post-audit responses.

• Continuously reviews, updates, and does resource allocation in Monday.com (project management tool) as it relates to claims audits and claims audit deliverables
• Serves as the primary lead for the daily CAP Committee, steering cross-departmental discussions, ensuring accountability, and guiding decision-making to address audit findings and compliance risks.
• Attends Claims Source System Validations with health plan partners. Leads initiatives to address and resolve findings from SSV if any. Implement and monitor corrective actions to ensure continuous process improvement
• Responsible for training and overseeing future Compliance Coordinator in the preparing of claims audit files.
• Develop, initiate, maintain, and revise claims compliance policies and procedures and job aids regarding audits and the internal audit workflow.

• Develop and deliver training for staff on audit requirements, compliance procedures, and continuous improvement initiatives.
• Review audit findings to identify trends, root causes, and potential compliance risks; ensure timely and effective implementation of corrective actions.

• Collaborate with internal departments and external stakeholders to validate audit data and resolve findings.
• Notifies Compliance upper management regarding any compliance issues for investigation and resolution.
• Coordinate with healthcare information technology team on audit universe generation and any deficiencies identified internally or externally by auditors
• Coordinate compliance activities with other departments and sources as necessary.
• Maintain professional and open communication with health plans regarding audits, audit related deliverables, and audit related deadlines.
• Assist with the development of Corrective Action Plans (CAPs) for regulatory agencies related to claims audits.
• Coordinate Compliance Claims audit related deliverables with Compliance Project Manager as needed to ensure timely and quality completion

• Promote a culture of compliance, accuracy, and accountability within the organization.
• Track and report audit results, metrics, and performance trends to senior leadership, health plans, and client boards as required.

• Perform other related duties as assigned.

Qualifications

• Bachelor’s degree in Business Administration, Health Care Administration, or related field preferred.
• Minimum of 5 years of experience in claims auditing, compliance, or managed care operations within a delegated MSO or health plan environment.
• Strong understanding of delegated oversight requirements, health plan delegation agreements, and regulatory frameworks (CMS, DHCS, DMHC, HIPAA).
• Experience managing or leading audit teams, compliance projects, and corrective action initiatives.
• Proficient with claims processing systems (EZ-Cap preferred), audit tracking tools, and Microsoft Office Suite (Excel, Word, PowerPoint).
• Demonstrated experience applying quality improvement methodologies, including Root Cause Analysis (RCA), and other problem-solving techniques to identify issues, implement corrective actions, and drive process improvement.
• Excellent written and verbal communication skills, with the ability to present findings to both operational and executive audiences.

Preferred Qualifications:

• Experience preparing for and responding to health plan oversight or regulatory audits.
• Knowledge of claims adjudication and delegated functions within managed care operations across all lines of business.

Working conditions

• This job may require flexible work hours due to the nature of the responsibilities.