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Job Summary
The Grievance and Appeals (G&A) Auditor is responsible for performing end-to-end audit of appeals and grievance cases. This role ensures compliance with applicable regulatory requirements, including standards established by the Centers for Medicare & Medicaid Services (CMS). The auditor evaluates case accuracy, procedural compliance, clinical and coverage determinations, and timeliness standards, while identifying opportunities for process improvement and risk mitigation.
Key Responsibilities
Primary duties may include, but are not limited to:
- Conduct pre- and post-resolution audits of member appeals and grievance cases across Medicare Advantage and other managed care lines of business.
- Ensure compliance with CMS Medicare Advantage Appeals and Grievance regulations, internal policies, and regulatory timeframes.
- Review case files for accuracy and completeness, including:
- Member eligibility and benefit coverage
- Medical necessity determinations
- Clinical rationale and supporting documentation
- Benefit interpretation and plan policy application
- Provider and member communications
- Validate that appropriate clinical and administrative review levels were applied throughout the appeals and grievance lifecycle.
- Assess adherence to CMS requirements for notices, including denial letters, appeal determinations, and grievance responses.
Audit & Compliance Oversight
- Identify procedural errors, compliance gaps, and documentation deficiencies.
- Evaluate timeliness of case resolution against regulatory standards.
- Document audit findings with clear rationale, regulatory citations, and impact assessments.
- Support audit readiness and regulatory examination activities.
Documentation & Reporting
- Prepare detailed audit reports outlining:
- Case review findings and decision accuracy
- Procedural and compliance deviations
- Financial, operational, or regulatory risk exposure
- Track audit outcomes to identify trends in appeals and grievance processing errors.
- Support reporting for compliance committees, regulatory audits, and internal quality initiatives.
Quality Improvement & Support
- Provide feedback to Grievance and Appeals teams regarding identified errors and improvement opportunities.
- Recommend corrective actions, training needs, and process enhancements.
- Identify systemic issues and collaborate with leadership, compliance, and operational teams to implement solutions.
- Escalate potential compliance risks or regulatory violations as appropriate.
Collaboration & Communication
- Partner with clinical reviewers, compliance officers, and operational leaders to resolve complex case issues.
- Communicate audit findings clearly to both technical and non-technical stakeholders.
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