Purpose:

The Director, Internal Audit – Healthcare Insurance is an enterprise audit leader responsible for setting the strategy and overseeing execution of risk-based internal audits across UPMC’s healthcare insurance and payer operations. Reporting directly to the Chief Audit Officer, this role owns the healthcare insurance audit universe and annual audit plan, conducts continuous risk assessment, and delivers high-impact assurance and advisory services with clear, actionable reporting to executive leadership.

The Director builds and leads a high-performing team, advances audit methodology through data analytics, automation, and continuous auditing, and partners constructively, while maintaining independence, with insurance operations, compliance, actuarial, finance, IT, and legal leadership. The role is expected to modernize the payer audit function, translate complex regulatory and operational risk into business impact, and strengthen control effectiveness, regulatory compliance, financial integrity, and member outcomes.

Responsibilities:

Strategy & Governance

• Set and own the healthcare insurance internal audit strategy, continuous risk assessment, and risk-based annual audit plan, aligned to enterprise priorities, regulatory requirements, and emerging payer risks.

• Maintain and continuously refresh a comprehensive healthcare insurance audit universe, including:

   

  • Claims adjudication, pricing, edits, payment accuracy, and recovery

  • Enrollment, eligibility, and member maintenance

  • Premium billing, accounts receivable, and revenue recognition

  • Coordination of Benefits (COB) and subrogation

  • Utilization management, medical necessity, and authorization processes

  • Provider contracting, fee schedules, reimbursement, and value-based arrangements

  • Pharmacy benefit management (PBM) and specialty pharmacy

  • Government programs (Medicare Advantage, Medicaid managed care, dual-eligible plans, risk adjustment)

  • Delegated entities, vendors, and third-party administrators

• Provide assurance and advisory services on emerging payer risks, including payment reform, interoperability, delegated oversight, regulatory change, and data-driven payment integrity.

• Ensure audit coverage aligns with applicable federal and state healthcare insurance regulations and contractual obligations.

Audit Delivery & Quality

• Lead audit planning, fieldwork, and reporting for healthcare insurance audits and special projects; ensure workpapers and evidence meet professional standards, including IIA Topical Requirements and Internal Audit methodology.

• Elevate audit quality through root-cause analysis, control design and operating effectiveness testing, and clearly articulated management action plans with measurable outcomes.

• Integrate data analytics and continuous auditing into payer audits (claims, enrollment, financial and operational datasets) to expand coverage, timeliness, and insight.

• Ensure audit programs are mapped to regulatory requirements, contractual terms, and recognized control frameworks.

• Collaborate on integrated audits with IT, compliance, clinical, financial, and ERM teams to address end-to-end payer risks.

Healthcare Insurance Operations & Regulatory Risk

• Assess effectiveness of claims processing and payment integrity controls, including pricing accuracy, timeliness, recoveries, and overpayments.

• Evaluate enrollment and eligibility controls, including onboarding, life-event changes, and termination accuracy.

• Review COB, subrogation, and recovery processes for compliance, accuracy, and financial impact.

• Assess utilization and medical management controls for regulatory compliance and alignment with plan requirements.

• Evaluate provider contracting and reimbursement controls, including amendments and value-based arrangements.

• Coordinate independent review of delegated entities and third-party vendors, including operational performance, compliance attestations, audit rights, and corrective actions.

• Research, interpret, and advise on regulatory and policy changes impacting healthcare insurance operations.

Stakeholder Engagement & Executive Communication

• Provide concise, risk-based insights and trend analysis to Internal Audit leadership and senior executives.

• Deliver timely, accurate audit reporting to the Chief Audit Officer for inclusion in executive briefings and governance materials.

• Maintain trusted relationships with insurance operations leadership, compliance, actuarial, finance, IT, and legal partners; influence remediation and risk prioritization while preserving audit independence.

• Collaborate with Enterprise Risk Management on payer-specific risk identification, metrics, and thematic reporting.

• Support regulatory exams and external audits through independent assessment and coordination, as appropriate.

People Leadership & Culture

• Recruit, develop, and retain healthcare insurance audit talent; provide coaching, clear performance expectations, and succession planning.

• Foster a culture of accountability, curiosity, and continuous improvement, with emphasis on payer operations, regulatory expertise, and data-driven auditing.

• Deliver timely feedback, recognize high performance, and promote professional development and engagement with relevant organizations.

Tools, Innovation & Methodology

• Drive modernization of healthcare insurance auditing through advanced analytics, automation, and continuous monitoring.

• Champion consistent and effective use of audit platforms (e.g., AuditBoard, TeamMate, or similar) for planning, workpapers, issue tracking, and reporting.

• Standardize audit programs, templates, and control libraries across payer processes to improve quality, scalability, and comparability.

• Continuously evolve methodology through benchmarking, lessons learned, and post-engagement reviews to maintain leading practices.

• Provide strategic oversight of payer-related audit technology and analytics initiatives, ensuring tools support business objectives and audit independence.