Director, Integrated Care Audit Management

Job Summary:

The Director, Integrated Care Audit Management provides strategic leadership and operational oversight for internal and external regulatory audits, quality reviews, and compliance activities across all Integrated Care products, markets, & businesses. In partnership with enterprise Compliance, IT, and Care Coordination leaders, this role directs audit readiness, coordinates regulatory responses and universe submissions, evaluates audit findings, and ensures timely completion of corrective action plans and other required deliverables.

The Director identifies and mitigates regulatory and operational risk by strengthening internal controls, aligning audit tools and processes with contractual, federal, state, CMS, Medicaid, Medicare, and NCQA requirements, and promoting consistent application of audit protocols. Through education, collaboration, and strategic stakeholder engagement, the Director advances audit preparedness, regulatory compliance, accountability, and continuous process improvement throughout the Integrated Care product.

Essential Functions: Collaborate with enterprise Compliance for all Federal, State and product specific audits conducted by regulators of Medicaid and Medicare programs for operationalization within Integrated Care product across all markets

Coordinate and direct all responses and follow-up to audit findings and draft audit reports. Monitor follow-up action plans on all audit findings for Integrated Care product and ensure timely submission

• Minimize risk to the company by responding to or supporting and assisting with the facilitation of Medicaid and Medicare audits in coordination with Compliance leaders
• Perform or coordinate specific audits to determine compliance, and if necessary, ensuring appropriate actions are taken to put the Integrated Care product in compliance
• Seek opportunities to educate the Integrated Care management and team on the importance of risk mitigation, effective internal controls and compliance with applicable regulations
• Partner with the business and IT teams for all universe creations. Review and approval of all universe submissions for the Integrated Care product for all markets
• Support the education of audit protocols for all markets
• Ensure accurate/timely completion of regulatory/compliance tasks requested for all external audits
• Identify care coordination auditing requirements for each Integrated Care product market and manage resources needed to drive compliance
• Ensure internal audit tools for care coordination meet the contractual, regulatory and NCQA requirements for Integrated Care products for all markets
• Present audit results and recommendations for process improvements to Care Coordination leadership monthly
• Provide at least quarterly status reports for the Integrated Care product Executive Leadership regarding internal & external audits and related issues
• Support the NCQA LTSS Distinction reporting requirements, as well as facilitation of periodic survey
• Maintain positive and strategic relationships with internal and external stakeholders

Perform any other job related duties as requested.

• Education and Experience: Bachelor's degree in business or related field required
• Master's degree in business or related field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of healthcare operations, managed care, or audit management experience required
• Three (3) years of CMS Program Audit experience required
• Three (3) years of previous management experience is required, audit management experience within healthcare operations preferred

Competencies, Knowledge and Skills: Demonstrated understanding of Compliance, Regulatory and Audit fundamentals specifically related to managed care and government programs audits (CMS/HHS/DOI/Medicaid/Marketplace and Medicare)

• Exceptional project management skills with a proven ability to lead complex audits and organizational initiatives in a matrixed environment
• Demonstrated strategic management and leadership skills, including decision-making and time management for audit facilitation and compliance adherence
• Intermediate-level proficiency in Microsoft Word, Excel, and PowerPoint to support audit deliverables and reporting
• Ability to work independently and within a matrixed environment
• Attention to detail and strong communication skills necessary
• Demonstrated critical listening and thinking skills
• Licensure and Certification: CHA, CHPC, CHCA, CPHQ or other similar certification preferred
• Working Conditions: General office environment; may be required to sit or stand for extended periods of time

May be required to work additional hours and/or outside normal business hours as needed to meet deadlines.

Remote Position

Travel is not typically required