Director of External Audits and Program Integrity

BHG Careers•Dallas, TX

About The Position

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. These include reviews by commercial payor Special Investigations Units (SIUs), Medicare and Medicaid program integrity contractors such as UPICs, state Medicaid agencies, and other government or third-party auditing entities. The Director oversees the full audit lifecycle, from initial notification and document requests through record production, findings, corrective action plans, appeals, and resolution. The role leads External Audit Specialists responsible for locating, retrieving, assembling, and producing medical records. The Director also serves as BHG’s subject matter expert on OTP care delivery and documentation, explaining OTP operations, workflows, and records to auditors and educating internal teams on clinical workflows and charting practices. The position requires practical OTP clinical and charting experience; experience interacting with auditors is helpful but can be taught. The Director partners with Compliance, Legal, Revenue Cycle, Clinical Operations, Medical Leadership, Finance, and executive leadership to develop audit strategies, assess findings and financial exposure, address root causes, and improve documentation, policies, workflows, and internal controls. Success is measured by timely and complete audit responses, accurate reporting of financial exposure, fewer recurring findings and auditor misunderstandings of OTP requirements, and consistent, reliable audit processes across BHG operations.

Requirements

Degree in nursing, social work, counseling, psychology, or a related clinical field.
Active, unrestricted clinical license or credential.
At least 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 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.
Ability to locate, analyze, and apply state- and payor-specific criteria chart by chart and claim by claim, including Medicare OTP benefit weekly bundled payment codes (G2067–G2080), add-on services, documentation requirements, eligible service providers and signers, and required timeframes.
Knowledge of state Medicaid, Medicaid managed care, and commercial payor OTP billing rules, including H0020 and related HCPCS codes, service definitions, unit and frequency limits, prior authorization, and differing provider manual requirements.
Knowledge of medical-necessity criteria for OTP admission and continued treatment, including OUD diagnosis, ASAM or other state- or payor-specified criteria, and documentation of medical necessity over time.
Ability to research and compare state regulations, Medicaid provider manuals, MCO contracts and policies, and commercial payor policies to determine applicable claim criteria and assess 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.

Nice To Haves

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.

Responsibilities

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; act as the central point of contact and manage the audit lifecycle through resolution.
Partner with Compliance, Legal, Revenue Cycle, Clinical Operations, Medical Leadership, and executive leadership on audit response strategies, audit-related issues, and corrective-action accountability.
Maintain centralized audit tracking and reporting for volume, status, findings, financial exposure, timeliness, and outcomes; provide executive leadership with updates on significant audits and emerging risks.
Explain OTP operations, workflows, and records to auditors and educate internal teams on OTP clinical workflows and charting practices.
Use working knowledge of SAMMS to explain chart creation and storage and identify and retrieve documentation supporting services under review, including dosing records, counseling notes, assessments, treatment plans, drug screens, and scanned or external documents.
Identify and produce requested OTP personnel training, onboarding, and credentialing records, such as licenses, credentials, training records, and background checks, while protecting employee privacy and limiting disclosure to what the audit requires.
Review charts to assess whether documentation supports billed services and distinguish documentation gaps from auditor misunderstandings of OTP requirements or workflows.
Lead, supervise, train, and develop External Audit Specialists; train them on OTP chart structure, SAMMS navigation, and documentation supporting each type of service under review.
Assign and prioritize record requests; monitor team workload, productivity, and accuracy; and provide coaching, feedback, and performance management.
Establish standardized procedures, checklists, and quality-review steps for record retrieval and production; review record packets for completeness and support before submission.
Evaluate preliminary and final audit findings for validity and financial exposure related to billing, medical necessity, clinical documentation, coding, and payor requirements; identify opportunities for clarification, rebuttal, or appeal.
Identify trends indicating broader compliance vulnerabilities, partner with clinical and operational leaders to investigate root causes, and recommend improvements to documentation, policies, workflows, and internal controls.
Oversee reconsiderations, appeals, and corrective action plans; track overpayment findings, repayment demands, and recoupment activity in partnership with Finance and Revenue Cycle.