Auditor, Provider Network (Medicare duals - MA State Health Plan)

Molina Healthcare • Pittsfield, MA • 9h ago

Job Description

Employee for this role must reside in Massachusetts

Job Summary

Provides audit support for contractual and regulatory compliance for specified providers in accordance with requirements established by state regulations. The role ensures provider adherence to applicable regulations through comprehensive audits, reviews, and investigations ensuring timely resolution and appropriate documentation. Analyzes audit results and compliance data to identify trends, risks, and recurring issues, and presents findings through written summaries, dashboards, and stakeholder-ready reporting to support regulatory readiness and continuous improvement. The position serves as a primary liaison between providers, internal departments, and regulatory agencies to support compliance, quality oversight, and regulatory readiness across the assigned territory.

Job Duties

Conducts outreach and schedule on-site and virtual meetings with specified providers within the assigned territory, including prospective and existing providers, in accordance with state requirements.

Analyze audit outcomes and compliance submissions to identify trends and risk signals (recurring deficiencies, late/insufficient documentation, repeat findings), and translate insights into actionable remediation priorities.

Develop, maintain, and distribute routine audit reporting (dashboards/scorecards, executive summaries, and regulator-ready status updates) that track audit completion, findings, corrective action progress, and closure timelines across the assigned territory.

Prepare and deliver clear presentations of audit findings and corrective action expectations to providers and internal stakeholders; facilitate follow-up meetings to validate remediation, document outcomes, and support ongoing regulatory readiness.

Performs and manages audits, ensuring timely completion and adherence to applicable standards.

Responds to all other time-sensitive requests as required.

Reviews, assesses, and evaluates submitted documentation and proof of compliance based on specific guidelines issued by the regulator. This includes, but is not limited to, review of policies and procedures, facility standards, staffing requirements, and operational practices.

Interprets applicable regulatory guidance to determine compliance status. Communicates determinations to providers and identify required remediation actions or completion steps, ensuring follow-up until resolution.

Investigates and responds to agency complaints, as well as handle all other related agency requests within established timelines.

Tracks, documents, and maintains accurate records of all actions, communications, audit outcomes, corrective action plans, and follow-up activities, including required reporting to the regulator and other oversight agencies.

Communicates proactively and collaborate with internal departments to ensure regulatory alignment, operational efficiency, and effective resolution of compliance matters.

Trains, mentors, and monitors newly hired team members to ensure consistent application of regulatory standards, audit protocols, and internal procedures.

Travels within the assigned territory to conduct on-site audits, provider meetings, complaint investigations, and regulatory reviews in order to meet oversight and compliance requirements.

Job Qualifications

REQUIRED QUALIFICATIONS:

At least 3 years contract-related experience in the health care field including, but not limited to, provider's office, managed care organization, or other health care or regulatory environment, or equivalent combination of relevant education and experience.

Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare

PREFERRED QUALIFICATIONS:

Experience building and deliveri ng audit summaries, compliance dashboards, or executive-ready reporting in PowerPoint for internal leadership and external stakeholders (including oversight entities, as applicable).

Experience working with large datasets, including trend analysis and root cause identification tied to audit outcomes, corrective actions, and provider performance.

Proficiency with data visualization tools (Power BI, Tableau, or similar) and strong command of Excel for analysis.

Familiarity with healthcare compliance and audit frameworks and operational oversight activities (for example delegated oversight or subcontractor monitoring), especially in Medicaid and Medicare @contexts.

MS Excel (Pivot Tables), PowerPoint, and Power BI

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $63,161 - $116,064 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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