Audit Specialist (Monitoring, Compliance, Quality and Program Integrity)
Remote
Full Time
Mid Level
Pay Range: $79K – 83K based on experience
Summary:
NHA is seeking an Audit Specialist to support Centers for Medicare & Medicaid Services’ (CMS) initiative designed to tackle fraud, waste and abuse (FWA) in Medicare Fee-for-Service (FFS) by using advanced technologies. The Audit Specialist will play a key role in ensuring program integrity, compliance, monitoring and quality in support of a comprehensive, data-driven monitoring program designed to safeguard model integrity, ensure adherence to regulatory and technological standards, and reduce risk to CMS and its beneficiaries.
Responsibilities and Duties:
The following reflects management’s definition of essential functions for this job but does not restrict the tasks that may be assigned. Management reserves the right to assign or reassign responsibilities, as necessary.
Qualifications:
Summary:
NHA is seeking an Audit Specialist to support Centers for Medicare & Medicaid Services’ (CMS) initiative designed to tackle fraud, waste and abuse (FWA) in Medicare Fee-for-Service (FFS) by using advanced technologies. The Audit Specialist will play a key role in ensuring program integrity, compliance, monitoring and quality in support of a comprehensive, data-driven monitoring program designed to safeguard model integrity, ensure adherence to regulatory and technological standards, and reduce risk to CMS and its beneficiaries.
Responsibilities and Duties:
The following reflects management’s definition of essential functions for this job but does not restrict the tasks that may be assigned. Management reserves the right to assign or reassign responsibilities, as necessary.
- Support the design, documentation, and implementation of a Monitoring Plan and Standard Operating Procedures (SOPs) for compliance and law enforcement screening activities.
- Identify, evaluate, and document key risks and compliance requirements, focusing on protecting beneficiaries, adherence to CMS agreements, and compliance with federal regulations.
- Collaborate with key stakeholders to map monitoring and compliance activities (e.g., audits, data analysis, and ongoing reviews) to program goals and risk areas.
- Contribute to methodologies for risk profiling, reporting, and lessons learned to promote continuous improvement in compliance and oversight activities.
- Conduct comprehensive annual audits and ad hoc audits to assess compliance with Participation Agreement provisions, prior authorization processes, and technology requirements.
- Perform data-driven analyses of participant-submitted data, claims, and quality outcomes to identify trends, outliers, and potential risks affecting beneficiary safety and program compliance.
- Verify participant adherence to timelines, data accuracy, and procedural requirements through review of submitted documentation and system data.
- Support virtual and document-based audit processes, including notifications, sampling strategy development, audit execution, scoring, and follow-up activities.
- Support quarterly CPI and law enforcement screenings and associated personnel using databases such as APS, PECOS, OnePI, and Do Not Pay (DNP).
- Prepare participant data lists, interpret screening results, and make recommendations for remedial actions in collaboration with CMS.
- Conduct environmental scanning to identify potential legal or conflict-of-interest (COI) concerns and assess program integrity implications.
- Maintain documentation of noncompliant participants and track corrective and preventive actions.
- Assist CMS and the project team in determining risk levels (low, moderate, high) for noncompliance findings.
- Recommend and support the implementation of remedial actions including corrective action plans (CAPs), noncompliance notifications, education and outreach, and other enforcement steps as appropriate.
- Maintain compliance history, audit findings, and participant-level risk ratings.
- Support structured lessons learned processes following monitoring and audit activities to improve future program performance and standardization.
- Develop and deliver quarterly monitoring and audit reports, summarizing compliance findings, key metrics, and recommended actions for CMS.
- Ensure findings are presented clearly and consistently using visual and narrative formats for CMS leadership and program stakeholders.
- Contribute to the creation and maintenance of remedial action and monitoring documentation within CMS-approved systems (e.g., SharePoint, Model Space).
- Support CMS engagement and communications through professional correspondence, technical assistance, and compliance education.
Qualifications:
- Bachelor’s degree in healthcare administration, public health, compliance, auditing, data analytics, or related field
- 3-5 years of Fee-For-Service (FFS) CMS experience in healthcare compliance, auditing, or federal program integrity initiatives
- Demonstrated experience conducting risk-based audits, compliance reviews, quality audits, and data analysis within federal healthcare programs or contractor environments.
- Proficiency with audit management systems, Excel, and data analytics tools (e.g., SAS, SQL, R, or Python) preferred
- Familiarity with Medicare and Medicaid policies, CMS Innovation Center models, and prior authorization regulations (including CMS-0057-F), preferred.
- Experience working with provider screening systems (APS, PECOS, OnePI) and compliance databases (DNP, LEIE) preferred.
- Salesforce experience
- Experience with MS Teams, Sharepoint, MS Suite
- Experience using and applying Artificial Intelligence (AI) in the workplace
- Strong analytical, writing, and organizational skills.
- Ability to synthesize complex regulatory information into actionable audit findings and reports.
- Commitment to integrity, accuracy, and confidentiality in all compliance activities.
- Excellent communication and stakeholder engagement skills to support collaborative compliance management.
- Versatility, flexibility, and willingness to work within constantly changing priorities
- Strong interpersonal skills
NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time.
NHA is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, sexual orientation, national origin, veteran status, disability or any other basis protected by law.
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