Internal Auditor

About the Role

We are seeking an experienced Internal Auditor with a strong background in managed healthcare and claims auditing to join our team. This role focuses on conducting audits across health plan operations—particularly claims, encounter data, payment integrity, utilization management, finance, compliance, and IT. The Internal Auditor will evaluate internal controls, ensure compliance with CMS and state Medicaid requirements, and provide recommendations that strengthen operational performance and reduce risk.

Lead and execute comprehensive audits with a primary focus on:

• Claims processing accuracy, timeliness, and adjudication workflows
• Medicare Advantage and Medicaid managed care compliance
• Encounter submissions, payment integrity, and over payment recovery
• Delegated entity and vendor oversight

Evaluate internal controls and operational processes related to:

• Claims adjudication systems
• Regulatory compliance (CMS, Medicaid, AHCA)
• Utilization management and authorization-to-claims match
• General finance and operational functions

Identify control gaps, inefficiencies, improper payments, or noncompliance with regulatory and contractual requirements.

Prepare clear, detailed audit reports with actionable recommendations.

Collaborate with leaders in Claims, Finance, Compliance, Clinical Services, and IT to implement improvements.

Track remediation progress and validate corrective actions.

Maintain forms in accordance with IIA Standards.

• Bachelor’s degree in Accounting, Finance, Business, Healthcare Administration, or related field.
• 3–5 years of internal audit experience specifically within a managed care organization or health plan.
• Hands‑on experience auditing claims processing, encounter data, or payment integrity functions.
• Understanding of Medicare Advantage, Medicaid managed care, CMS regulations, and program integrity standards.
• Strong analytical skills and proficiency with audit methodologies and Microsoft Office Suite.

• Experience with claims platforms (e.g., QNXT, Facets, Diamond, or similar).
• CIA, CISA, CHC, or other relevant healthcare audit/compliance certifications.
• Familiarity with data analytics tools (ACL, Power BI, Tableau, etc.).

• High attention to detail and ability to work independently.
• Strong analytical and critical‑thinking capabilities.
• Ability to manage multiple audits concurrently and meet deadlines.
• Excellent communication and report‑writing skills.
• High ethical standards and commitment to confidentiality.

Reports to:

Chief Financial Officer