Director, Audit Services - Community First Health Plans CFHP

University Health; San Antonio (TX); On-site; USD 90,000 - 140,000; Full time

Job summary

Community First Health Plans seeks a Director of Audit Services to lead and oversee healthcare audit activities within CFHP. The role ensures operations align with HHSC, TDI, CMS, and NAIC requirements, collaborating with leaders across the organization to promote a team-oriented audit function.

The ideal candidate has a bachelor’s degree in accounting or healthcare and at least three years of professional healthcare audit experience, with preference for a master’s degree and professional

Qualifications

• Bachelor’s degree in accounting or healthcare-related field with 3+ years of professional healthcare audit experience.
• Experience interpreting Texas Medicaid Managed Care regulations, Texas Department of Insurance regulations, and HHSC OIG Medicaid Managed Care SIU regulations.
• Experience with anti-fraud detection and prevention.
• Master’s degree preferred; supervisory experience preferred.
• Professional certifications such as CHC, CIA, CPA, or CFE preferred.
• Expert knowledge of ICD, CPT, HCPCS coding classifications and DRG, APC, and ASC payment methodologies desirable.

Responsibilities

• Collaborate with leaders and departments across the audit function to promote a team-oriented environment.

Skills

Healthcare audit

Anti-fraud detection

Regulatory interpretation

Team collaboration

Education

Bachelor's degree in accounting or healthcare-related field

Master's degree preferred

Professional certifications (CPA/CIA/CHC/CFE)

Job description

Director, Audit Services - Community First Health Plans CFHP

Community First Health Plans, Inc. (Community First) is a Health Maintenance Organization (HMO) providing health care services to Medicaid, CHIP, Medicare, and Marketplace recipients. Community First also provides commercial and self-funded insurance to members. Community First must ensure that all operations are aligned with the regulatory requirements of the Texas Health and Human Services Commission (HHSC), the Texas Department of Insurance (TDI), the Centers for Medicare and Medicaid Services (CMS), and the National Association of Insurance Commissioners (NAIC). Collaborates with all leaders and departments throughout the course of the audit function, promoting a team-oriented environment.

EDUCATION/EXPERIENCE

Bachelor’s degree is required in accounting or healthcare-related field with at least three years’ experience in professional healthcare audit services, interpretation of Texas Medicaid Managed Care regulations, Texas Department of Insurance regulations, and/or HHSC OIG Medicaid Managed Care SIU regulations. Experience with anti-fraud detection and prevention is required. A master’s degree in accounting or related field is preferred. Supervisory experience is preferred. Experience with NAIC Model Audit Rule (MAR) audits and Enterprise Risk Management (ERM) is preferred. Must possess at least one or more relevant professional certifications (i.e., CHC, CIA, CPA, CFE). Preference will be given to a Certified Internal Auditor with AHIMA Coding Certification. Expert knowledge of ICD, CPT, HCPCS coding classifications and DRG, APC, and ASC payment methodology is highly desirable.