This position is responsible for partnering with divisional and enterprise leadership to minimize risks by ensuring an appropriate system of internal controls is in place and operating effectively. The Director serves as a key liaison to Horizon’s Internal Audit and Compliance departments in coordinating the division’s MAR and Enterprise Risk Management (ERM) programs. This position also directs a team of auditors accountable for performing Quality, Provider & Internal Audits in accordance with company policy, state and federal regulations and contractual requirements, reporting the results of such audits to internal and external stakeholders.

• Oversees the provider claim audit function to ensure compliance with Medicaid, Medicare, and Commercial business policies and procedures including development of annual risk assessment, audit plan and reporting. Identifies potentially inappropriate provider billing trends that can result in medical cost reduction and claim leakage.
• Collaborates with senior leaders and business owners to identify such billing trends and develop corrective action plans (CAP).
• Develops, maintains, and improves audit tools to identify risk and track financial impacts.
• Develops and reviews analytics to identify inappropriate provider billing. Improves and streamlines audits for efficiency and effectiveness.
• Collaborate and develop relationships with enterprise internal audit, external auditors, and Finance process owners to identify opportunities for improvement of internal controls, compliance with regulations and risk mitigation.
• Report audit readiness, preparedness and risk to senior leadership and key stakeholders. Work with various levels within the organization to ensure audits are completed and audit issues are closed timely. Provide assistance to external auditors and third-party vendors in the performance of Horizon audits.
• Oversee the Quality Audit function of TPA and internally processed claims, adjustments, and recoveries to identify potential claim payment issues including identification of root cause analysis.
• Develop and maintain effective internal communication and reporting protocols including the use of dashboards and other reports for regular divisional leadership staff meetings. Document and communicate the results of claim payment and other ad-hoc auditing performed to Finance Senior Leadership and key internal and external stakeholders.
• Serves as a key resource for Finance, Service and Provider Contracting Departments, directing numerous ad-hoc audits to identify root cause and assist with development of remediation plans.
• Collaborate with Enterprise Risk Management on emerging risks and support the development of mitigation plans.

• High School Diploma/GED required.
• Bachelor degree in Finance, Accounting preferred or relevant experience in lieu of degree.
• Prefers a Master’s in Business Administration (MBA).
• Requires a minimum of ten (10) years of experience with progressive responsibility in the health care industry, preferably in finance and/or auditing.
• Requires five (5) years audit experience, preferably within the health insurance industry.
• Requires supervisory staff management and administrative experience.

• CIA, CISA, CFE or CPA preferred.

• Requires in-depth knowledge of GAAS and the COSO Enterprise Risk Management Integrated Framework.
• Requires in-depth knowledge of accounting procedures and internal controls.
• Requires in-depth knowledge of financial reporting requirements.
• Prefers knowledge of BCBSA reporting requirements.

• Requires demonstrated ability to manage multiple high-level projects simultaneously.
• Requires ability to build strong inter and intra departmental relationships.
• Demonstrated experience in successfully building relationships at the senior leadership level.
• Executive presence, poise, and confidence.
• Demonstrated aptitude for analytical thinking and the ability to report findings in an accurate manner.
• Must have effective verbal and written communication skills and demonstrate the ability to express thoughts clearly and concisely, both orally and in writing.
• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Demonstrated ability to make decisions with little need for direction and to function effectively as a team-oriented self-started working across cross-functional and cross-divisional lines.

• Travel required as needed.

$133,900 - $182,805

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement