Remote Lead Auditor — IDR Entity Audit (CMS)

We are building a team to deliver the Independent Dispute Resolution (IDR) Entity Audit for the Centers for Medicare & Medicaid Services (CMS), in support of the Departments of Health and Human Services, Labor, and the Treasury (the Tri-Departments). 

Enacted as part of the Consolidated Appropriations Act of 2021, the No Surprises Act (NSA) protects patients from unexpected out-of-network medical bills. When an insurer and an out-of-network provider cannot agree on a payment amount, the Federal IDR Process allows a certified IDR entity to determine the appropriate payment. Our team will independently audit those certified IDR entities to verify that their eligibility and payment determinations are compliant with the NSA and its implementing regulations — directly supporting decisions about certification, recertification, and revocation.

The Lead Auditor is responsible for managing and directing audits of certified IDR entities to meet timeliness and quality standards. The Lead Auditor leads the design and execution of Eligibility Determination Audits and Payment Determination Audits, supervises project audit teams, and serves as the technical authority for audit methodology, sampling, workpapers, findings, and recommendations.

This is a fully remote position. The place of performance is at the contractor’s site, not at a CMS facility, so the selected candidate may work from any location within the Continental United States. Occasional travel to CMS offices in Baltimore, MD may be required for milestone reviews or stakeholder meetings.

This role is ideal for a credentialed audit professional with deep healthcare program-integrity expertise who can deliver disciplined, defensible audits that support CMS’s certification, recertification, and revocation decisions for certified IDR entities.

• Ensure audits are performed in a consistent, impartial, and objective manner across all certified IDR entities.
• Supervise project audit teams, including assignment of work, mentoring, and review of junior auditors’ output.
• Manage and execute completion of assigned tasks within established timelines for standard and expedited audits.
• Provide quality control over audit workpapers, evidence, findings, and recommendations to ensure each audit is well-documented and defensible.
• Review the project team’s audit work, including documentation supporting eligibility and payment determination findings, and the rationale documented in draft audit reports.
• Provide technical assistance to CMS and project staff on audit methodology, including statistically representative sampling design, treatment of single vs. batched disputes, handling of reopened determinations, and assessment of clerical, procedural, or jurisdictional errors.
• Review audit reports and other deliverables and interact with the client on program and technical issues, including the Audit Strategy, individual audit reports, and the Preliminary and Final Annual Audit Reports.
• Apply knowledge of Generally Accepted Accounting Principles (GAAP), Government Auditing Standards (GAS), and applicable Federal regulations — including guidelines, standards, and concepts — and other relevant industry practices to each engagement.
• Assess certified IDR entity compliance with eligibility determination requirements (including batching, State All-Payer Model Agreements, and specified State law applicability), payment determination procedures, recordkeeping, and reporting timeframes.
• Identify recurring issues, emerging trends, and “red flags” for escalation; support calculation of financial impact (e.g., collected but unremitted administrative fees) where applicable.
• Safeguard sensitive healthcare information and ensure audit execution complies with the No Surprises Act, 45 CFR 149.510, and all contract security and privacy requirements.

• Minimum of seven (7) years of relevant work experience managing performance audits or programs involving enrollment data, as well as the audit of financial information and payments.
• Current CFE (Certified Fraud Examiner) and/or CPA (Certified Public Accountant) credential — mandatory.
• Demonstrated experience reviewing the work of junior auditors and leading multi-member audit teams.
• Working knowledge of GAAP, Government Auditing Standards (Yellow Book), and Federal regulatory frameworks applicable to healthcare audits.
• Strong written communication skills, including the ability to author and review audit findings, workpapers, recommendations, and corrective action narratives suitable for publication on the CMS No Surprises Act website.
• Bachelor’s degree in accounting, finance, healthcare administration, or a related field; advanced degree preferred.
• Availability and commitment to serve in the Key Personnel role for the full period of performance; a signed letter of commitment will be required at proposal submission for any candidate not already employed by the prime contractor or a proposed subcontractor.
• Ability to obtain and maintain any required CMS security and privacy clearances and to complete CMS-required training.

• Experience managing data and program integrity-related projects or programs.
• Prior healthcare audit, compliance, or program integrity experience with CMS, HHS, other Federal or State agencies, payers, providers, facilities, or arbitration/dispute resolution programs.
• Familiarity with the Federal IDR process, certified IDR entity operations, and the interplay between Federal requirements and specified State laws or All-Payer Model Agreements.
• Additional credentials such as CIA (Certified Internal Auditor), CISA, CHC (Certified in Healthcare Compliance), or AHFI (Accredited Health Care Fraud Investigator).
• Experience designing statistically representative sampling plans for audits of variable-volume case populations.