Delegation Audit Specialist

About Capital Rx 

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.

Location: Remote (For Non-Local) or Hybrid (Local to NYC area) 

Position Summary: 

The Delegation Audit Specialist plays a critical role in ensuring Capital Rx meets its contractual and regulatory obligations to health plan clients. This role is responsible for the end-to-end process of client-initiated pre-delegation and annual delegation audits, including coordination, documentation, monitoring and oversight for timely response across all internal stakeholder groups. The ideal candidate excels at project management, has deep familiarity with delegation audit frameworks, and is comfortable working cross-functionally to align documentation with compliance standards and contractual obligations. 

Position Responsibilities: 

• Serve as the primary coordinator and single point of accountability for all incoming delegation audits from health plan clients and/or their designees. 
• Manage the full audit lifecycle, including intake, task assignments, timelines, document tracking, status updates, and final submission. 
• Draft or coordinate comprehensive responses to audit requests, ensuring accuracy, timeliness, and alignment with CMS, URAC, NCQA, and state-level standards. 
• Lead cross-functional audit response meetings, clarify roles and expectations, and ensure stakeholder accountability. 
• Maintain audit response trackers, document repositories, and response templates to streamline future audits. 
• Partner with Legal, Compliance, Operations, and Client Success to obtain accurate materials, attestations, and policy documentation. 
• Provide support to client-facing teams by offering guidance on delegation audit protocols and expectations. 
• Implement a centralized audit dashboard to monitor audit status, deadlines, and risk indicators across all client audits. 
• Develop and maintain a risk scoring system for delegation entities based on audit findings, frequency of issues, and responsiveness. 
• Track response times and completion rates by department to identify bottlenecks and improve cross-functional collaboration. 
• Monitor audit outcomes and client feedback to inform process improvements and training initiatives. 
• Align delegation audit activities with broader compliance monitoring efforts, including CAP tracking and risk assessments. 
• Develop monthly and quarterly audit performance reports for Compliance leadership and the Compliance Committee. 
• Contribute to audit readiness initiatives and internal mock audits to enhance response quality and reduce risk. 
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance 

Minimum Qualifications: 

• Bachelor’s degree in a relevant discipline (e.g., Healthcare Administration, Business, Public Policy, or related field). 
• Minimum of three (3) years of experience in pharmacy benefit management, managed care, or health plan compliance. 
• At least two (2) years of direct experience managing delegation audits, client audits, or accreditation reviews. 
• Strong project management and organizational skills; proven ability to lead and coordinate cross-functional initiatives. 
• Excellent verbal and written communication skills. 
• Working knowledge of applicable regulatory and accreditation standards (e.g., CMS Part C/D, URAC, NCQA, and state Medicaid agencies). 
• Proficiency in Microsoft Office tools. 

Preferred Qualifications: 

• Familiarity with audit tracking systems such as Jira or similar workflow management platforms. 
• Demonstrated understanding of PBM core functions including claims adjudication, prior authorization, pharmacy network management, and utilization management. 
• Experience collaborating with client-facing teams and managing sensitive client communications in high-stakes audit scenarios. 

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.