Manager, Healthcare Operations Audit

About the position The Manager, Healthcare Operations Audit in Health Plan Operations is responsible for overseeing and managing the audit function within the health plan, ensuring compliance, accuracy, and operational efficiency across all relevant business processes. This role is essential in assessing and auditing key operational areas such as Utilization Management (UM), claims processing, call center operations, administrative functions, and other health plan services. The Audit Manager leads a team of auditors, provides strategic insights into audit findings, and drives process improvements based on audit results. Additionally, the role ensures that audits comply with all relevant regulatory requirements, internal policies, and industry best practices.

Responsibilities

• Oversee and direct the audit process for all relevant areas, including Utilization Management, claims, call center, and administrative functions.
• Manage and mentor a team of auditors, providing guidance, training, and professional development.
• Develop and implement audit strategies and plans to ensure comprehensive coverage of key operational areas.
• Ensure that audits are conducted in accordance with established schedules, regulations, and industry standards.
• Conduct audits across multiple departments to evaluate operational efficiency, compliance, and accuracy.
• Review and assess processes, procedures, and documentation to identify gaps, inefficiencies, and areas for improvement.
• Ensure that audits encompass key areas such as UM intake, authorization review, claims processing, and related departmental functions.
• Analyze audit data, assess trends, and provide actionable insights for improving operational performance.
• Ensure audits are performed in compliance with relevant healthcare regulations, such as CMS guidelines, state-specific requirements, NCQA standards, and industry best practices.
• Collaborate with regulatory and compliance teams to ensure that audit findings align with internal compliance policies.
• Stay up-to-date with changing regulations and adapt audit strategies accordingly to maintain compliance across health plan operations.
• Prepare detailed audit reports, including findings, recommendations, and corrective action plans for management and other stakeholders.
• Present audit results and key observations to senior leadership, highlighting critical issues and offering solutions for process improvements.
• Maintain organized and accurate records of audit activities, results, and resolutions for internal tracking and compliance purposes.
• Identify root causes of audit discrepancies and work with internal teams to implement corrective actions and preventive measures.
• Develop and promote best practices for operational processes to enhance efficiency and reduce the risk of non-compliance or errors.
• Collaborate with cross-functional teams to design and implement improvements in operational workflows based on audit findings.
• Lead and supervise a team of auditors, ensuring timely completion of audits and promoting a collaborative work environment.
• Provide coaching and feedback to team members, fostering a culture of continuous learning and improvement.
• Work closely with department heads across Utilization Management, Claims, A&G, and other operations to resolve audit issues and improve performance.
• Serve as the primary point of contact for audit-related inquiries from internal departments and external auditors.
• Build strong working relationships with key stakeholders across the organization to drive accountability and facilitate audit process improvements.
• Engage with external auditors, regulatory bodies, and industry peers to remain informed on emerging trends, compliance requirements, and best practices.

Requirements

• Bachelor's degree in Healthcare Administration, Business Administration, Nursing, or a related field (required).
• Master's degree in Healthcare Administration, Business Administration, or a related field is preferred.
• Professional certifications such as Certified Internal Auditor (CIA), Certified Healthcare Auditor (CHA), Certified Professional in Healthcare Quality (CPHQ), or similar certifications are highly desirable.
• A minimum of 5-7 years of experience in healthcare operations, auditing, or compliance, with at least 2-3 years in a managerial or leadership role within health plan operations or managed care organizations.
• Extensive experience auditing key healthcare functions, including Utilization Management (UM), claims processing, customer service, call center operations, and other administrative services.
• Proven track record of leading and managing audit teams, developing audit plans, and delivering insights into operational and compliance performance.
• Experience with regulatory requirements such as CMS, NCQA, and state-specific healthcare regulations.
• A demonstrated ability to assess risk, identify opportunities for improvement, and drive actionable change based on audit results.
• Strong leadership and team management skills, with the ability to motivate and guide audit teams to achieve objectives.
• Excellent analytical and problem-solving skills, with the ability to assess complex operational processes and identify areas for improvement.
• Exceptional verbal and written communication skills, including the ability to present audit findings and recommendations to senior leadership and other stakeholders.
• High attention to detail and the ability to maintain accuracy and quality in all audit-related activities.
• Proficiency with audit management software, healthcare management systems, and MS Office Suite (Excel, Word, PowerPoint).
• Strong knowledge of healthcare claims processing and customer service operations is essential.
• Ability to manage multiple priorities and deadlines in a fast-paced, dynamic environment.

Nice-to-haves

• Master's degree in Healthcare Administration, Business Administration, or a related field.
• Professional certifications such as Certified Internal Auditor (CIA), Certified Healthcare Auditor (CHA), Certified Professional in Healthcare Quality (CPHQ).

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