Director – Internal Audit Operations

Jobtailor; Alhambra (CA); On-site; USD 140,000 - 180,000; Full time

Job summary

Jobtailor in California is seeking a senior internal auditor to lead a risk-based operational audit program spanning claims, utilization, credentialing, and revenue cycle. You will direct end-to-end engagements, perform risk assessments across markets, and present findings to executive leadership.

The role requires 10+ years in internal or operational auditing, healthcare industry experience, and strong data analytics with SQL, Power BI, or Tableau.

Qualifications

• Bachelor's degree or equivalent practical experience in Accounting, Finance, Business, Healthcare Administration.
• 10+ years of internal/audit experience, including end-to-end engagements.
• Healthcare experience in a health plan, IPA, MSO, or provider organization.
• Ability to quantify impact of control failures and defend analyses.

Responsibilities

• Build and maintain a risk-based operational audit plan covering claims, encounters, utilization and care management, credentialing, provider data, revenue cycle, delegated functions, and vendor oversight.
• Conduct annual operational risk assessments across markets, entities, and lines of business.
• Lead operational audits end to end, including scoping, walkthroughs, control identification, sampling, testing, workpaper documentation, and reporting.
• Test claims adjudication, payment integrity, encounter submission and acceptance, authorization and denial handling, credentialing, re-credentialing, and provider roster accuracy.
• Audit claims and membership data supporting actuarial reserve estimates.
• Audit risk adjustment operations, including diagnosis coding, chart review and retrieval, encounter data, and validation-audit readiness.
• Audit compliance with CMS, DMHC, DHCS, and health plan delegation standards.
• Use data analytics against full populations and build repeatable scheduled tests.

Skills

Operational Auditing

Healthcare Compliance Auditing

Data Analytics Proficiency

Risk Assessment

Audit Methodology Development

Education

Bachelor's degree in Accounting, Finance, Business, Healthcare Administration

CIA, CPA, CISA, CHC, or CFE certification (preferred)

Tools

SQL

Power BI

Tableau

Audit Management Platforms

Job description

• Build and maintain a risk-based operational audit plan covering claims, encounters, utilization and care management, credentialing, provider data, revenue cycle, delegated functions, and vendor oversight
• Conduct annual operational risk assessments across markets, entities, and lines of business
• Lead operational audits end to end, including scoping, walkthroughs, control identification, sampling, testing, workpaper documentation, and reporting
• Test claims adjudication, payment integrity, encounter submission and acceptance, authorization and denial handling, credentialing, re-credentialing, and provider roster accuracy
• Audit claims and membership data supporting actuarial reserve estimates
• Audit risk adjustment operations, including diagnosis coding, chart review and retrieval, encounter data, and validation-audit readiness
• Audit operational inputs to risk pool and shared-risk settlements
• Audit compliance with CMS, DMHC, DHCS, and health plan delegation standards
• Use data analytics against full populations and build repeatable scheduled tests
• Perform post-close operational reviews of acquired organizations
• Write findings with conditions, quantified impact, root cause, recommendations, owners, and due dates
• Present audit results and risk trends to executive leadership and the Audit Committee
• Track remediation to closure and independently validate corrective actions
• Identify systemic enterprise issues across engagements
• Establish audit methodology, workpaper standards, quality review, and reporting cadence consistent with IIA standards
• Partner with Finance and SOX audit
• Advise business leaders on control design for new processes, markets, and health plan arrangements
• Manage, mentor, and develop audit staff and co-source resources
• Maintain the internal audit charter and present the annual risk-based audit plan to the Audit Committee
• Arrange periodic external quality assessments and conduct internal quality reviews
• Support fraud, waste and abuse work and investigations, coordinating with Compliance and Legal

Requirements

• Bachelor's degree in Accounting, Finance, Business, Healthcare Administration, or a related field, or equivalent practical experience
• 10+ years of internal audit, operational audit, compliance auditing, or process improvement experience, including experience leading engagements end to end
• Healthcare experience in a health plan, IPA, MSO, provider organization, or healthcare-focused advisory practice
• Working knowledge of claims, encounters, utilization management, credentialing, provider data, or revenue cycle
• Ability to quantify the impact of a control failure and defend the analysis to process owners
• Strong analytical skills, including SQL or comparable data tools
• Ability to work independently against large and imperfect operational datasets
• Excellent written and verbal communication skills, including presenting to senior executives and governance committees
• Sound judgment and independence
• Preferred: CIA, CPA, CISA, CHC, or CFE certification
• Preferred: Experience with delegated oversight audits under CMS, DMHC, DHCS, or NCQA delegation standards
• Preferred: Experience auditing or operationalizing controls in a post-acquisition integration
• Preferred: Familiarity with value-based care economics, including capitation, shared savings, risk pools, and incentive programs
• Preferred: Experience building an operational audit function or materially expanded audit plan
• Preferred: Proficiency with audit management platforms and BI tools such as Power BI or Tableau

Core Competencies

Demonstrates expertise in operational auditing, risk assessment, and compliance within healthcare environments, with a strong focus on claims, encounters, and revenue cycle management. Proficient in data analytics and effective communication with executive leadership to drive audit findings and recommendations.

Highest-signal resume keywords

• Operational Audit Leadership
• Healthcare Compliance Auditing
• Data Analytics Proficiency
• Risk Assessment Expertise
• Audit Methodology Development

ATS Optimization Keywords

Hard Skills

• Operational Auditing
• Risk Assessment
• Claims Adjudication
• Data Analysis
• Control Identification
• Sampling and Testing
• Workpaper Documentation
• Quality Review
• Process Improvement
• Audit Reporting

Soft Skills

• Analytical Skills
• Written Communication
• Verbal Communication
• Judgment
• Independence

Certifications & Qualifications

• CIA
• CPA
• CISA
• CHC
• CFE

Industry Keywords

• Healthcare Administration
• Claims Management
• Utilization Management
• Credentialing
• Revenue Cycle
• CMS Standards
• DMHC Standards
• DHCS Standards
• NCQA Standards
• Value-Based Care

Tools & Technologies

• SQL
• Power BI
• Tableau
• Audit Management Platforms