Medical Records Audit Manager

About Zealie LLC

Zealie is a fast-growing Medical Billing company specializing in the Behavioral Healthcare industry. Our clients are substance use disorder treatment, addiction recovery, and mental health treatment centers that are saving lives on a daily basis. Our state of the art proprietary technology provides data analytics and revenue prediction tools to our clients to help them make strategic business decisions to grow their business. We are committed to delivering exceptional products and services to our clients and believe that our team plays a crucial role in achieving this mission. We are seeking motivated individuals with a desire to be a part of a winning team.

Job Summary

The Audit Manager leads the day-to-day operations of the Audit Unit within the Payer Compliance and Medical Records Department. This role holds operational accountability for two critical functions: the Audit Operations Team and the Audit Resolution Team.

Zealie currently partners with over 200 behavioral health facilities nationwide, actively navigating dozens of concurrent payer audits (consistently averaging 40+ active facility audits with dynamic volume fluctuations). The Audit Manager oversees the end-to-end lifecycle of payer audit inquiries—ranging from pre-payment medical necessity reviews to complex retrospective (post-payment) reviews.

The ideal candidate blends high-level organizational mastery with exceptional communication skills, seamlessly interfacing with facility owners, health plan administrators, third-party payers, employers, and executive leadership to protect client revenue and maintain rigorous compliance.

Key Responsibilities & Duties

1. Team Leadership & Daily Operations

• Supervise, mentor, and direct the daily workflows of both the Audit Operations Team (intake, records prep, submission) and the Audit Resolution Team (disputes, appeals, final determinations).
• Manage resource allocation, capacity planning, and staff assignments across Team Leads, Subject Matter Experts (SMEs), and Specialists.
• Direct hiring, onboarding, continuous training, and performance evaluations across both teams.
• Cultivate best-in-class audit defense and appeals strategies across all levels of behavioral healthcare (Detox, RTC, PHP, IOP, OP, Aftercare).

2. Audit Workflow & Case Management

• Manage the complete lifecycle of payer audit requests across 200+ partner facilities, actively handling 40+ dynamic audits at any given time.
• Direct the intake, validation, medical record packet assembly, and timely response submission for all pre-payment reviews and retro review audit requests.
• Oversee the investigation of audit findings, coordinate second-level appeals, and drive dispute resolution to overturn denials and recover revenue.
• Serve as the senior escalation point for high-stakes audits, complex payer clawbacks, and urgent payer deadlines.

3. Production Tracking, Reporting & Quality Control

• Maintain and optimize centralized audit tracking systems to log deadlines, record submissions, payer correspondence, and determination statuses.
• Monitor, measure, and report daily/weekly team production metrics, accuracy benchmarks, and throughput KPIs to senior leadership.
• Implement structured quality control (QC) checkpoints to ensure all submitted documentation, clinical charts, and cover letters meet stringent payer requirements and HIPAA regulations.

4. Stakeholder Communication & Relationship Management

• Act as the primary liaison and strategic communicator for audit matters, maintaining transparent, professional, and confident interactions with:
• • Facility Owners & Executive Directors: Providing real-time updates, audit trends, documentation risk assessments, and final audit outcome reports.
  • Payers & Plan Administrators: Managing formal inquiries, dispute calls, and technical submission verifications.
  • Employers & Benefit Coordinators: Clarifying coverage requirements and documentation guidelines when applicable.
  • Internal Leadership: Collaborating with Utilization Review, Billing, and Account Management teams to address systemic payer trends and clinical documentation vulnerabilities.

Qualifications & Experience

Required Qualifications:

• Experience: Minimum of 4–5 years of healthcare revenue cycle management (RCM) or medical records compliance experience, with at least 2+ years in a supervisory or managerial leadership role overseeing audit, appeals, or compliance teams.
• Audit Expertise: Proven, hands-on experience managing both pre-payment reviews (Additional Documentation Requests / ADRs) and retroactive / post-payment audits directly with commercial payers, Medicaid, and Medicare.
• Communication: Exceptional verbal, written, and presentation skills. Proven track record communicating directly with C-suite stakeholders, facility owners, payer medical directors, and internal executives.
• Organizational Mastery: Superior project management and organizational skills, with demonstrated capability handling 40+ concurrent, high-volume audit files across multiple client facilities without missed deadlines.
• Regulatory Knowledge: Deep understanding of HIPAA privacy regulations, CMS guidelines, medical necessity criteria, and state healthcare compliance mandates.
• Technical Proficiency: High proficiency in Electronic Health Record (EHR) platforms, billing clearinghouses, and Google Workspace (Google Sheets, Docs, Drive).

Preferred Qualifications:

• Behavioral Health Specialization: Deep familiarity with behavioral health, mental health, and substance use disorder (SUD) billing, levels of care (Detox, Residential/RTC, Partial Hospitalization/PHP, Intensive Outpatient/IOP, Outpatient/OP), and clinical documentation standards (ASAM/LOCUS criteria).
• Education & Certifications: Bachelor’s or Associate’s degree in Health Information Management (HIM), Healthcare Administration, or related field. Relevant certifications (e.g., RHIA, RHIT, CPC, CPMA, or CHC) are a strong plus.

Core Competencies

• Operational Execution: Ability to balance micro-level quality review with macro-level production management.
• Analytical Problem-Solving: Ability to dissect complex payer denial trends and formulate compelling appeal strategies.
• Diplomacy & Client Facing Acumen: Calm, authoritative communication when delivering updates on contentious payer clawbacks or high-exposure audits.