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Delegation Oversight Program Claims Auditor

Summary

The Delegation Oversight Program Claims Auditor oversees auditing and performance monitoring of delegated entities managing the RKK Client Claims functions. This role ensures compliance with applicable state and federal standards and supports corrective initiatives when deviations arise.

Duties and Responsibilities:

• Conduct pre-delegation and annual audits, including risk assessment, and utilize tools for oversight of Claims operations.


• Monitor and evaluate delegate performance—tracking metrics on timeliness, denial rates, regulatory adherence, and complaint trends.


• Maintain RKK Client’s audit tools, workflows, and compliance documentation aligned with RKK Client Health standards.


• Identify deficiencies; collaborate with delegates to create and implement Corrective Action Plans (CAPs).


• Prepare and deliver audit reports and performance summaries to RKK Client’s oversight committees


• Serve as a liaison and subject matter expert—providing guidance, regulatory updates, and performance feedback to internal stakeholders and RKK Client Leadership Team.


• Coordinate multidisciplinary meetings (e.g., operations, quality, UM committees) to align oversight activities.


• Support pre-audit readiness and external reviews for accreditation or regulatory compliance.

Minimum Job Requirements:

• Bachelor’s degree (healthcare administration, health services) or equivalent experience.


• Experience in delegation oversight, UM, claims auditing, or managed care compliance.


• Solid understanding of NCQA, CMS, Medicaid, and CA Medi-Cal regulatory frameworks.


• Strong analytical, communication, and auditing skills.


• Proficient in Microsoft Office; experience with audit tools and data tracking systems.

Skills and Abilities:

• Ability to manage multiple audits and follow-up processes efficiently.


• Collaborative and consultative approach to delegate performance improvement.


• Keen attention to detail with a proactive mindset for quality assurance.

Salary Range:

• $72k-$85k annually

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