Director of External Audits and Program Integrity

Director, External Audits & Program Integrity

Department: Compliance
Reports To: Chief Compliance Officer or Designee
Location: TBD
FLSA Status: Exempt

Position Summary

Behavioral Health Group (BHG) is seeking an experienced Director of External Audits & Program Integrity to lead the organization's response to external healthcare audits, payor investigations, and regulatory reviews, including those conducted by commercial payor Special Investigations Units (SIUs), Medicare and Medicaid program integrity contractors such as Unified Program Integrity Contractors (UPICs), and other government or third-party auditing entities. The Director will oversee the full audit lifecycle, from initial notification and document requests through findings, corrective action plans, appeals, and resolution, and will lead a team of External Audit Specialists responsible for locating, retrieving, assembling, and producing medical records in response to audit requests.

The ideal candidate is a credentialed clinician with deep, hands-on experience in the opioid treatment program (OTP) space. Experience interacting with auditors is helpful but can be taught; practical OTP clinical and charting experience is essential.

Key Responsibilities

External Audit Management & Oversight

• Lead responses to external audits and investigations by commercial payor SIUs, UPICs, Medicare and Medicaid contractors, state Medicaid agencies, and other regulatory or payor entities, serving as the central point of contact for auditors and managing the full audit lifecycle, from initial requests and record production through findings, corrective actions, and resolution, to ensure all submissions are accurate, complete, and timely.
• Partner with Compliance, Legal, Revenue Cycle, Clinical Operations, Medical Leadership, and executive leadership to develop audit response strategies, resolve audit-related issues, and establish accountability for corrective actions.
• Maintain centralized audit tracking and reporting on audit volume, status, findings, financial exposure, timeliness, and outcomes, and provide executive leadership with regular updates on significant audits and emerging risks.

OTP Clinical Documentation & Auditor Education

• Serve as the organization's subject matter expert on how OTP care is delivered and documented, explaining OTP operations, workflows, and records to auditors and educating internal teams on OTP clinical workflows and charting practices.
• Apply working knowledge of SAMMS to explain how charts are created and stored, and to identify and retrieve the specific documents needed to support each service under review, including dosing records, counseling notes, assessments, treatment plans, drug screens, and scanned or external documents.
• Apply detailed knowledge of OTP personnel training, onboarding, and credentialing requirements to identify, retrieve, and produce the specific HR file documentation auditors request (such as licenses, credentials, training records, and background checks), while protecting employee privacy and disclosing only what the audit requires.
• Review charts to determine whether documentation supports billed services and identify where findings reflect a documentation gap versus an auditor's misunderstanding of OTP requirements or workflows.

Team Leadership – External Audit Specialists

• Lead, supervise, and develop a team of External Audit Specialists responsible for locating, retrieving, assembling, and producing medical records in response to audit and payor requests, and train them on OTP chart structure, SAMMS navigation, and the documentation required to support each type of service under review.
• Assign and prioritize record requests, and monitor team workload, productivity, and accuracy, providing ongoing coaching, feedback, and performance management.
• Establish standardized procedures, checklists, and quality review steps for record retrieval and production, and review record packets before submission to confirm they are complete and fully support the services under review.

Findings, Appeals & Program Integrity

• Evaluate preliminary and final audit findings for validity and financial exposure related to billing, medical necessity, clinical documentation, coding, and payor requirements, and identify opportunities for clarification, rebuttal, or appeal.
• Identify patterns and trends that indicate broader compliance vulnerabilities, partner with clinical and operational leaders to investigate root causes, and recommend improvements to documentation, policies, workflows, and internal controls to reduce recurring findings.
• Oversee reconsiderations, appeals, and corrective action plans, and track overpayment findings, repayment demands, and recoupment activity in partnership with Finance and Revenue Cycle.

Required Qualifications

• Clinical background with a degree in nursing, social work, counseling, psychology, or a related clinical field.
• Active, unrestricted clinical license or credential.
• Minimum of 5 years of direct experience working in an opioid treatment program (OTP) setting.
• Hands-on experience with OTP electronic medical records, preferably SAMMS, including how charts are created, stored, and retrieved.
• Thorough knowledge of OTP documentation requirements across the patient journey, including each step of intake and ongoing monthly and annual requirements under federal (42 C.F.R. Part 8), state, and payor rules.
• Expert-level, demonstrable command of Medicare and Medicaid billing, reimbursement, documentation, and medical necessity requirements as they apply to OTP services. Because these requirements vary significantly by state and by payor, the candidate must be able to locate, analyze, and apply each state's and payor's specific criteria chart by chart, claim by claim, including:
  • The Medicare OTP benefit, including weekly bundled payment codes (G2067–G2080) and add-on services, and the documentation elements required to support each billed service, including who may provide and sign the service, required timeframes, and what must appear in the chart.
  • State Medicaid, Medicaid managed care, and commercial payor OTP billing rules (e.g., H0020 and related HCPCS codes), including how service definitions, unit and frequency limits, prior authorization, and provider manual requirements differ from state to state and payor to payor.
  • Medical necessity criteria for OTP admission and continued treatment, including OUD diagnosis, ASAM or other state- or payor-specified criteria, and how medical necessity is established and maintained in the record over time.
  • How to research and compare state regulations, Medicaid provider manuals, MCO contracts and policies, and commercial payor policies to determine which criteria govern a claim and whether a finding is valid, applies the wrong standard, or should be challenged.
• Demonstrated experience supervising, training, and developing staff, and working across Compliance, Revenue Cycle, Clinical Operations, and Legal functions.
• Strong analytical, investigative, organizational, and communication skills, including the ability to explain OTP clinical practices to auditors, present complex findings to senior leadership, and manage multiple high-priority audits and deadlines.

Preferred Qualifications

• Experience managing UPIC, SIU, RAC, MAC, Medicaid Program Integrity, or other payor audits, including overpayment determinations, recoupments, and administrative appeals.
• Leadership experience in an OTP, such as program director, clinical supervisor, or nursing supervisor.
• Professional certification such as CPMA, CPC, CCS, RHIA, or another relevant healthcare coding, auditing, or health information credential, in addition to clinical licensure.

Success Measures

Success in this role will be measured by timely and complete audit responses, accurate identification and reporting of financial exposure, reduction in recurring audit findings, reduction in findings driven by auditor misunderstanding of OTP requirements, and consistent, reliable audit processes across BHG's operations.

BHG is an equal opportunity, affirmative action employer providing equal employment opportunities to applicants and employees without regard to race, color, religion, age, sex, sexual orientation, gender identity/expression, national origin, protected veteran status, disability status, or any other legally protected basis, in accordance with applicable law.