Clinical Eligibility Auditor

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Analytica

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B2B • Government • Consulting

Analytica is a rapidly growing SBA-Certified 8(a) Small Business that specializes in providing advanced analytics, digital transformation, and enterprise data management services primarily to federal agencies. The company focuses on simplifying complex data to enable its clients to make informed decisions, thereby driving success in their missions and citizen services. With a strong emphasis on management consulting and federal technology training, Analytica employs a data-driven approach to enhance the capabilities of government IT systems and organizations. The company is renowned for its collaborative culture and commitment to employee development, ensuring quality service delivery. Analytica is recognized for its support in public sector innovation and adheres to industry standards like Agile, SAFe, and CMMI. Their mission is to assist the government in utilizing digital tools and data analytics to improve service delivery to citizens.

51 - 200 employees

🤝 B2B

🏛️ Government

📋 Description

• Conduct detailed reviews of Medicaid and CHIP eligibility determinations to ensure compliance with federal and state regulations • Evaluate eligibility determinations related to applications, renewals, post-Public Health Emergency (PHE) unwinding activities, and subsequent regulatory updates • Apply clinical judgment to cases involving disability criteria, functional limitations, medical necessity, long-term care pathways, or medically complex eligibility scenarios • Assess state Medicaid eligibility policies, procedures, and operational workflows for consistency with regulatory and clinical requirements • Identify and analyze vulnerabilities, risks, or non-compliance issues, including those with clinical implications • Review and interpret medical records, disability assessments, functional evaluations, and other clinical and administrative documentation • Use data analytics and case review insights to identify trends, patterns, and high-risk areas for deeper clinical or eligibility analysis • Prepare or contribute to comprehensive audit reports summarizing findings, root causes, clinical considerations, and corrective actions for CMS/CPI and CMCS • Produce clear, well-documented evidence to support audit conclusions and clinical determinations • Serve as a clinical subject-matter expert (SME), advising the audit team on medically complex or ambiguous eligibility cases • Collaborate with state agencies to obtain documentation, clarify processes, and understand clinical elements of eligibility decisions • Participate in coordination meetings to ensure alignment across clinical and eligibility review activities • Stay current on federal and state Medicaid eligibility pathways, clinical criteria, and regulatory guidance • Assist in developing and refining audit tools, templates, and methodologies to incorporate clinical considerations • Support quality assurance efforts by verifying the accuracy and validity of clinical and regulatory findings before submission • Mentor and support junior auditors and team members as needed • Contribute to ongoing improvement of audit protocols, processes, and training materials • Effectively manage workload, timelines, and documentation requirements in a fully remote environment

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license required • Bachelor of Science in Nursing (BSN) required; Master’s degree (e.g., MSN, MPH, MHA) preferred • Minimum 3 years of professional nursing experience, which may include utilization review, care management, clinical eligibility determinations, Medicaid-related work, or healthcare compliance • Experience with Medicaid and/or CHIP programs—such as eligibility, coverage determinations, managed care, or long-term services and supports (LTSS)—strongly preferred • Proficiency in Microsoft Office applications • Experience reviewing clinical and administrative records and translating findings into written analyses • Ability to contribute to technical audit reports and presentations

🏖️ Benefits

• Competitive compensation with opportunities for bonuses • Employer-paid healthcare • Training and development funding • 401k match