Delegation Oversight Auditor/Coordinator - Hybrid in Dallas, TX

Description

We are seeking a highly skilled Delegation Oversight Auditor/Coordinator with deep knowledge of Payor Credentialing regulatory requirements, including NCQA, URAC, CMS, and State-specific standards. This role plays a critical part in supporting and maintaining delegated relationships with National, Regional, and Local Health Plans across multiple states.

The ideal candidate will lead audits, manage contract compliance, and ensure data integrity to support our Physician Manpower and managed care strategy and ensure continuous adherence to credentialing delegation standards.

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 Audit & Oversight: 

• Lead and participate in delegation oversight audits conducted by Health Plans as well as NCQA Accreditation Audits.
• Ensure credentialing and recredentialing practices meet regulatory and contractual requirements (NCQA/URAC/CMS/State).
• Prepare and maintain documentation required for delegation readiness and ongoing compliance. 

Contract Management: 

• Review, redline and negotiate delegation agreements and contracts with Health Plans to align with internal strategy and regulatory obligations. 
• Ensure clear definitions of roles, responsibilities, reporting metrics, and performance expectations across internal teams to ensure adherence. 

Data Integrity & Reporting: 

• Monitor and maintain provider data integrity to ensure alignment with contractual requirements, timely participation dates and claims payments. 
• Oversee timely and accurate reporting to payors, including rosters, performance metrics, and audit responses. 
• Manage resolution of data discrepancies and claim loading issues in partnership with internal teams and health plan contacts.

Provider Network Compliance: 

• Support onboarding and maintenance of provider portfolios to ensure adherence to credentialing and contracting standards. 
• Track and resolve delayed claims and credentialing issues due to data (delayed loads) or authorization gaps to ensure we mitigate the loss of patient care and/or revenue. 
• Collaborate with internal credentialing, contracting, and operations teams to ensure alignment with health plan expectations.
• Proactively identify issues or risks to compliance and escalate appropriately to the Director when required or necessary. 
• Maintain detailed documentation to support audits, internal reviews, and health plan submissions.
• Ensure accurate and timely loading of provider data to avoid claims delays or denials. 

Stakeholder Collaboration: 

• Act as liaison between internal departments and external health plan partners. 
• Build and maintain positive working relationships with stakeholders at all levels, including executive leadership. 

Root Cause & Issue Resolution: 

• Investigate root causes of compliance or operational issues and drive corrective action. 
• Support efforts to improve delegation performance, reduce claims delays, and enhance provider onboarding workflows.

Qualifications

Education: 

• Bachelor’s Degree in Healthcare Administration, Business, or related field preferred. Equivalent experience may be considered. 

Experience: 

• Minimum 3–5 years of experience in Delegation Oversight, Credentialing, Managed Care, or Health Plan auditing. 
• Strong understanding of credentialing standards from NCQA, URAC, CMS, and State regulations. 
• Experience working with national and regional payors and understanding of managed care contracting structures. 

Skills & Competencies: 

• Excellent verbal and written communication skills.
• High attention to detail and organizational skills.
• Ability to manage multiple priorities in a fast-paced environment. 
• Strong analytical and problem-solving skills, including root cause analysis.
• Proficiency in identifying and resolving claim and data load issues. 
• Capable of obtaining and verifying authorizations and referrals when necessary. 
• Adept at contract review and negotiation with an understanding of delegated credentialing frameworks.