Program Integrity Auditor

Alliance Health

. Conduct routine and targeted post-payment and prepayment audits of Medicaid and State funded providers .

Posted 10/13/2026full-timeMorrisville • North Carolina • United StatesMid-LevelSenior💰 $69,592 - $88,729 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare compliance, auditing, and regulatory analysis, with a strong understanding of Medicaid laws and claims adjudication standards. Proficient in developing audit plans, conducting investigations, and presenting findings to leadership and compliance committees.

Highest-signal resume keywords

Healthcare ComplianceAuditing ExperienceMedicaid KnowledgeClaims Adjudication StandardsRegulatory Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Audit PlanningMedical Record CollectionBilling AnalysisPolicy DevelopmentData DocumentationCompliance ReviewTechnical AssistanceQuality-of-Care RecognitionProvider CredentialingIncident Report Analysis

Soft Skills

IntegrityConfidentialityCommunicationPresentation SkillsAnalytical Thinking

Tools & Technologies

Healthcare Fraud ShieldAudit ToolsCompliance PlansProvider Documents

Certifications & Qualifications

AHFICFECPMACPCCHCCLEAR Certified InvestigatorLCSWLCMHCLMFTLCAS

Industry Keywords

MedicaidBehavioral HealthMCO FunctionsFederal/State LawsAccreditationGrievance ManagementUtilization ReviewsProvider AppealsPost-Payment AuditsPrepayment Audits

About the role

Key responsibilities & impact

Conduct routine and targeted post-payment and prepayment audits of Medicaid and State funded providers
Develop audit plans and tools based on services to be audited
Request and collect medical records, personnel records, policies/procedures, compliance plans, and other provider documents
Collect, document, and store audit evidence accurately
Identify inappropriate billing and improper payments
Document audit activities and findings in detailed reports
Present audit results to leadership and Compliance Committee
Attend appeal hearings to present and explain review findings
Review newly enrolled providers for eligibility, qualifications, and licensure requirements
Research clinical policies, administrative code, and federal/state laws for noncompliance
Analyze claims, authorizations, enrollment, grievances, prior audits/investigations, incident reports, and policy data
Utilize Strategy and Healthcare Fraud Shield report data during audits
Educate providers on audit errors and provide technical assistance
Recognize quality-of-care issues and recommend action to appropriate entities/authorities
Document improper payment charts and statements of deficiency
Follow up on provider corrective action
Prepare for and participate in provider appeals and court hearings
Travel between Alliance offices, meetings, sponsored events, provider/member/stakeholder meetings, and court hearings

Requirements

What you’ll need

Bachelor's degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law, from an accredited College/University
Three (3) years of post-degree experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience
Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge preferred
Certification from AHFI, CFE, CPMA, CPC, CHC, or equivalent preferred
CLEAR Certified Investigator (Basic and Specialized) preferred
Clinical license as an LCSW, LCMHC, LMFT, LCAS, or LPA preferred
Knowledge of the Alliance Health service benefit plans and network providers
Knowledge of state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs
Knowledge and proficiency in claims adjudication standards & procedures
General understanding of major MCO functions, including prior authorization, utilization reviews, grievance management, provider credentialing and monitoring
High degree of integrity and confidentiality required when handling personal and confidential information
Must be available to report onsite to the Home Office for business meetings as needed
Travel throughout Alliance catchment area and surrounding counties as needed

Benefits

Comp & perks

Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
Dress flexibility