External Audit & Quality Assurance Compliance Analyst

POSITION SUMMARY:

The External Audit & Quality Assurance Compliance Analyst supports the organization's compliance program by coordinating external audits, ensuring adherence to regulatory standards and providing timely response. This role is critical in monitoring and improving the health plan's operational processes, compliance with federal and state regulations, and readiness for external evaluations. This role conducts Quality Assurance reviews for audit readiness. This role is external facing with interphase with regulators.

Position: External Audit & Quality Assurance Compliance Analyst

Department: Compliance

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

External Audit Coordination

• Act as the primary liaison, ensuring strong communication & relationship between the health plan and the external auditors, including regulatory agencies, accreditation organizations, and delegated entities.

• Prepare, review, and submit required documentation and data requests timely and organized manner to support external audits (e.g., CMS program audits, Payment Integrity Audit, state Medicaid reviews, or Network Adequacy).

• Track audit findings, assist in the development of corrective action plans, and ensure timely resolution and follow-up.

Quality Assurance Monitoring

• Conduct regular quality assurance reviews of health plan operations, focusing on compliance with regulatory requirements, policies, and procedures to ensure proactive audit readiness.

• Evaluate performance metrics, identify areas of non-compliance, and recommend process improvements.

• Ensure the accuracy and completeness of data and materials submitted to regulators and auditors.

Regulatory Compliance Support

• Monitor updates to federal and state regulations and communicate their impact on health plan operations.

• Assist in the development and maintenance of policies and procedures to align with evolving regulatory requirements.

• Provide compliance support to internal departments and delegated entities to ensure consistent understanding and application of standards

Data Analysis and Reporting

• Analyze audit and quality assurance results to identify trends and risks.

• Prepare detailed reports and summaries for leadership, compliance committees, and other stakeholders.

• Track and monitor key compliance metrics to measure the health plan's performance.

Training and Education

• Assist in the development and delivery of training programs to educate staff on audit readiness, quality assurance processes, and compliance requirements.

• Provide guidance to internal team

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Bachelor's degree in healthcare administration, business, compliance, or a related field is required.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Certification in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), or similar is required.

EXPERIENCE:

• Minimum of 5 years of experience in healthcare compliance, auditing, or quality assurance, preferably in a health plan environment is required.

• Experience supporting regulatory external audits such as CMS Program Audit, CMS 1/3 Financial Audit, External Quality Review, Encounter Data Validation, Network Adequacy is highly desirable.

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Strong knowledge of federal and state healthcare regulations, including Medicare and Medicaid compliance requirements.
• Excellent organizational and project management skills with attention to detail.
• Proficiency in data analysis and reporting tools (e.g., Excel, Tableau, or similar).
• Strong written and verbal communication skills.
• Ability to work collaboratively with cross-functional teams and manage multiple priorities.

Equal Opportunity Employer/Disabled/Veterans