Clinical Eligibility Auditor

Analytica is seeking a Clinical Eligibility Auditor to support the State Medicaid Program Integrity Audit (SMPIA) project, a national initiative dedicated to strengthening accountability, accuracy, and integrity across Medicaid programs in the United States. This role integrates clinical expertise with regulatory and eligibility auditing to support federal oversight activities and improve program performance and beneficiary protections.

Analytica has been recognized by Inc. Magazine as one of the fastest-growing 250 businesses in the United States for three consecutive years. We support U.S. government clients in health, civilian, and national security missions to build solutions that improve daily life for millions of Americans. Analytica offers competitive compensation with opportunities for bonuses, employer-paid healthcare, training and development funding, and a 401k match.

Responsibilities include (but are not limited to):

The Clinical Eligibility Auditor will:

• 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.

Minimum Qualifications:

• 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.

• Prior experience in audit, compliance, quality review, utilization management, or program integrity 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.

• Strong understanding of Medicaid clinical pathways, disability-related eligibility criteria, and coverage requirements.

• Familiarity with regulatory compliance, clinical documentation standards, and healthcare program integrity principles.

• Understanding of risk-based review methodologies and audit frameworks.

• Excellent analytical, organizational, and time-management skills.

• Strong written and verbal communication abilities, with the skill to explain complex clinical concepts to non-clinical audiences.

• Ability to work independently and collaboratively within a multidisciplinary team.

• Ability to maintain productivity and accountability in a fully remote work environment.

• U.S. citizenship, Green Card, or valid work authorization (H-1B).

Analytica LLC is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all individuals, regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other characteristic protected by applicable federal, state, or local law. As a federal contractor, we comply with the Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA) and take affirmative action to employ and advance in employment qualified protected veterans.

We ensure that all employment decisions are based on merit, qualifications, and business needs. We prohibit discrimination and harassment of any kind. Analytica LLC also provides reasonable accommodations to applicants and employees with disabilities, in accordance with applicable laws

When receiving email communication from Analytica, please ensure that the email domain is analytica.net to verify its authenticity.

Analytica LLC is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all individuals, regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other characteristic protected by applicable federal, state, or local law. As a federal contractor, we comply with the Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA) and take affirmative action to employ and advance in employment qualified protected veterans.

We ensure that all employment decisions are based on merit, qualifications, and business needs. We prohibit discrimination and harassment of any kind. Analytica LLC also provides reasonable accommodations to applicants and employees with disabilities, in accordance with applicable laws

When receiving email communication from Analytica, please ensure that the email domain is analytica.net to verify its authenticity.