Vendor Auditor - High Risk Provider

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Under the general supervision of the Department Director, the Vendor Auditor - High Risk Provider 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 oversees the day-to-day performance of the organization's highest-risk vendor portfolio by evaluating claims accuracy, assessing vendor performance, reviewing performance ratings, identifying operational risks, and recommending corrective actions.

The Vendor Auditor - High Risk Provider analyzes medical, pharmacy, and Pharmacy Benefit Manager (PBM) claims data to assess payment accuracy, identify trends and discrepancies, and conduct root cause analysis. Responsibilities include monitoring vendor compliance with contractual requirements and Service Level Agreements (SLAs), evaluating vendor performance against established standards, and maintaining vendor performance scorecards. The role also prepares formal audit reports, presents findings to leadership and oversight committees, tracks remediation efforts, and collaborates with internal stakeholders and external vendors to support accountability and continuous improvement.

The ideal candidate has advanced knowledge of claims adjudication, Medicare and Medicaid reimbursement, authorizations, appeals, and healthcare reimbursement policies. Experience managing vendor portfolios, evaluating vendor performance ratings, and working with high-risk providers is highly desirable. Familiarity with reviewing and interpreting vendor contracts is a plus. Success in this role requires strong analytical, critical-thinking, communication, and interpersonal skills, along with the ability to work independently, manage multiple priorities, and effectively collaborate with stakeholders to mitigate risk, improve vendor performance, and ensure compliance with organizational and regulatory standards.

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.

Salary Range: Minimum 28.90/hour - Maximum 47.71/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

The Hospital reserves the right to modify employee schedules as needed.

We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.