Vendor Auditor [Remote]

Position Summary

Under the general supervision of the Department Director, the Vendor Auditor is responsible for independently conducting claims and vendor performance audits to ensure compliance with contractual obligations, regulatory requirements, and Johns Hopkins Health Plans' quality standards. This position manages the day-to-day oversight of the organization's highest-risk vendor population by evaluating claims accuracy, monitoring vendor performance, identifying operational risks, and recommending corrective actions.

The Vendor Auditor analyzes medical, pharmacy, and PBM claims data to assess payment accuracy, performs root cause analysis of identified trends and discrepancies, and reviews vendor compliance with contracts and Service Level Agreements (SLAs). This role prepares formal audit reports, presents findings to leadership and oversight committees, monitors remediation efforts, and maintains vendor performance scorecards.

The ideal candidate possesses advanced knowledge of claims adjudication, Medicare and Medicaid reimbursement, authorizations, appeals, and healthcare reimbursement policies. Success in this role requires exceptional analytical, critical thinking, communication, and interpersonal skills, along with the ability to work independently, manage multiple priorities, and effectively collaborate with internal stakeholders and external vendors to promote continuous quality improvement.

Requirements: 

College Degree, preferred degree in Nursing, Accounting, Business, or Healthcare.  Primary preference is a Nursing degree.  Three (3) years of advanced claims auditing experience will be considered in lieu of college degree.