Buscar empleo: 50 ofertas de trabajo de medical reviewer en Clifton, New Jersey (septiembre 2026)

Director of Internal Audit

hace 11 días

Kearny

Job DescriptionDescription: Position Summary Children's Specialized ABA is investing in an independent internal audit function as a core part of its compliance and risk infrastructure. As the organization scales, the ability to systematically verify that billing, credentialing, and clinical documentation controls are working is a strategic priority for protecting revenue integrity, payer relationships, and regulatory standing. The Director of Internal Audit will own this build. In the near term, that means personally designing and executing the monthly audit program; over time, it means standing up a team and an operating model that can sustain that level of rigor without the Director performing every review personally. This is both a hands-on execution role and a function-design role: the person we hire will need to be equally comfortable pulling a sample and writing findings themselves, and thinking several steps ahead about how this function should be structured and staffed as the organization grows. The role also carries strategic accountability for how the organization presents itself to external payers during audits and medical records requests - coordinating the internal contributors who assemble documentation, applying a risk lens to what is submitted, and ensuring the organization's response reflects well on its overall compliance posture. This person will not personally pull every record but is accountable for the process and the judgment applied to it. Key Responsibilities • Design the monthly audit methodology including the sampling approach, testing procedures, and documentation standards within the scope and cadence established with leadership., • Personally select a representative monthly sample of providers across states and payers and execute audit testing across all required areas until a team is hired and trained to take on this work. Testing areas should include:, • Provider credentialing and licensure: confirm sampled providers are credentialed with relevant payers and that licensure/state registration is current and in good standing., • HR file completeness: confirm each sampled provider (BCBA or BT/RBT) has a resume on file, with any gaps greater than 6 months explained and documented., • Client file completeness: confirm that every client assigned to sampled providers has a signed handbook, intake form, and financial responsibility agreement on file., • Authorization and documentation: verify that clients assigned to sampled providers have valid authorizations, referrals, and CDEs in place., • Billing and coding accuracy: review claims for sampled providers/clients for accuracy and completeness and assess whether the day-to-day review process (prebilling QA, designated reviewer follow-up) is functioning as intended, not just whether errors exist., • Clinical documentation and medical necessity: assess whether session notes support medical necessity and evaluate whether clinical flags generated by NoteGuardAI are being reviewed and corrected before billing. Translate Findings Into Organizational Improvement • Partner with process owners to provide guidance and best practices for organizational improvement, treating every audit finding as an opportunity to strengthen how the organization operates, and staying engaged until the underlying process is genuinely better, not just documented., • Shape the organization's monthly dialogue on risk and quality through executive reporting that captures both audit outcomes and broader themes - where the organization is strong, where it's exposed, and where leadership's attention should be focused., • Track issues to true resolution rather than surface closure and connect the dots across audit cycles so the organization is solving root causes and anticipating risk, rather than chasing recurring symptoms. Own the Organization's External Audit Posture • Serve as the accountable owner for the organization's response to payer-initiated records requests and billing audits, coordinating across the Authorizations, RCM, and Clinical Quality functions that assemble the source records and documentation., • Review compiled submissions for completeness, accuracy, and audit risk in advance of the submission deadline, escalating any item that presents a risk of failing the audit to leadership for discussion., • Coordinate final review and approval and oversee timely submission to the payer through the organization's designated secure channels., • Support the organization's response to recoupment or adverse audit findings, coordinating documentation and internal stakeholders as leadership and legal counsel determine appeal strategy. Build and Lead the Internal Audit Team • Define the target structure, staffing plan, and workflows for an internal audit team as the function matures beyond a single practitioner, with a business case for headcount tied to organizational growth and risk exposure., • Recruit, hire, train, and manage audit staff; hand off sampling, testing, and documentation workflows while retaining accountability for audit quality, methodology, and executive reporting., • Establish quality-control and review processes so audit output remains consistent and defensible as the team grows., • Continuously refine audit scope and testing procedures as regulations, payer requirements, and organizational risk areas evolve, positioning the function to anticipate risk rather than simply respond to it. Qualifications Required • 8+ years of progressive experience in healthcare internal audit, compliance, or regulatory/payer audit functions; prior experience building or scaling an audit or compliance function is strongly preferred., • Working knowledge of Medicaid and commercial payer billing requirements; ABA, behavioral health, or other therapy-services billing experience is a significant plus., • Demonstrated experience reviewing clinical documentation for medical necessity and evaluating provider credentialing/licensure compliance., • Track record of managing or coordinating high-stakes, deadline-driven external audit or records-request processes with a payer, regulator, or accreditation body., • Ability to operate as an individual contributor initially, paired with the strategic judgment and leadership instincts to design and grow a function others will eventually run., • Strong written communication skills; able to produce clear, defensible audit findings and executive-level reporting that informs organizational decision-making., • Bachelor's degree in accounting, healthcare administration, nursing, or related field; or certifications in internal audit. Preferred • Experience with Central Reach or comparable ABA practice management/EHR systems, and with payer billing QA/flagging tools., • Experience operating under a dual reporting structure (e.g., finance and operations) and partnering closely with compliance and legal stakeholders. What Success Looks Like • A repeatable, well-documented monthly audit program is live and defensible within the first two audit cycles., • Process gaps are identified, escalated, and tracked to resolution rather than simply reported. Recurring patterns inform broader risk conversations with leadership., • External payer audit responses are submitted on time, with no last-minute scrambles and clear accountability across contributors., • Within 12–18 months, a functioning internal audit team is in place, with workflows handed off and quality maintained, and the function is positioned as a trusted strategic partner to leadership rather than a back-office check. Requirements:

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