You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
The Delegation Oversight Program Claims Auditor oversees auditing and performance monitoring of delegated entities managing the Restricted Knox-Keene licensed client claims functions. This role ensures compliance with applicable state and federal standards and supports corrective initiatives when deviations arise.
Responsibilities / Job Duties
- 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 Education and Experience Qualification Requirements
Education
- High school diploma or GED
Qualifications
- 3-5+ years experience specifically within Delegation Oversight (Must have health plan audit experience in the delegated environment).
- 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.
Experience
3-5+ years experience specifically within Delegation Oversight (Must have health plan audit experience in the delegated environment).
Skills
- Strong analytical, communication, and auditing skills.
- Proficient in Microsoft Office; experience with audit tools and data tracking systems.
Schedule / Shift
Monday - Friday 8am-5pm, working Pacific Standard Time
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
Required Employment / Compliance Language
Medix is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients
