Auditor, Delegate Utilization/Case Management

Role Overview

• Conduct UM/CM audits in accordance with regulatory, contractual, and industry standards
• Execute Utilization Management (UM) and Case Management (CM) audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
• Evaluate delegated entities’ compliance with CMS and contractual requirements, and Alignment Healthcare’s UM/CM policies and standards.
• Maintain organized, complete, and audit-ready documentation to support regulatory, accreditation, and internal oversight reviews.
• Ensure all audit activities align with the enterprise audit strategy and risk-based approach established by the Manager, Audit Administration.
• Engage delegated provider organizations to correct deficiencies and improve performance
• Communicate audit scope, expectations, timelines, required documentation, and process steps clearly to delegated entities throughout the audit lifecycle.
• Present audit findings to delegates, explaining root causes, performance gaps, non-compliance risks, and potential operational impacts related to UM/CM processes.
• Support delegated entities in understanding UM/CM compliance requirements and expectations for corrective actions.
• Foster professional, collaborative relationships to promote transparent discussions, accountability, and continuous improvement.
• Perform risk assessment and prioritize UM/CM audits
• Contribute to identifying high-risk areas by reviewing historical audit results, monitoring data, clinical performance trends, and operational challenges related to UM/CM.
• Recommend prioritization of UM/CM audits based on severity of risk, regulatory sensitivity, and emerging compliance or clinical performance trends.
• Provide input to refine audit scopes and schedules in alignment with the Manager’s risk-based UM/CM audit strategy.
• Escalate emerging UM/CM-related risks, irregular findings, or potential systemic issues to the Manager for strategic review and future audit planning.
• Validate corrective actions for UM/CM compliance
• Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses UM/CM deficiencies identified during audits.
• Assess evidence including revised workflows, updated clinical review criteria, policy changes, revised documentation, and utilization management decision processes.
• Track CAP progress and ensure follow-up activities are completed, documented, and closed in accordance with departmental requirements.
• Escalate irregular, stalled, or complex CAP issues to the Manager, Audit Administration for higher-level intervention.
• Report UM/CM audit findings to facilitate organizational awareness
• Prepare clear, concise, and well-structured audit summaries that highlight key risks, compliance gaps, operational issues, and improvement opportunities across UM/CM delegated functions.
• Contribute to audit reporting tools, dashboards, and documentation used for internal leadership, cross-functional teams, and enterprise oversight groups.
• Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal stakeholders to ensure findings are understood, actionable, and integrated into broader performance improvement efforts.
• Support preparation of audit materials and evidence for internal committees, external regulatory bodies, and executive-level oversight forums.
• Manage multiple UM/CM audits concurrently, ensuring adherence to established timelines, quality standards, and documentation requirements.
• Monitor UM/CM operational, clinical, and compliance data to identify emerging issues requiring targeted audit review.
• Support the development and delivery of training and education for delegated entities on UM/CM standards, audit expectations, and compliance requirements.
• Assist in preparing documentation and evidence for CMS or other regulatory audits.

Requirements

• 3-5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of clinical operations of managed care operations.
• Prior Medicare Managed Care UM/CM experience related to delegation oversight and auditing.
• 1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers
• Demonstrable detailed knowledge/experience with CMS, HICE, or related UM/CM requirements.
• Required: Bachelor’s Degree in nursing or equivalent
• Preferred: Master’s degree in nursing or related fields (e.g., MHA, MPH, MBA, MSN)
• Required: Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing UM/CM.
• Exceptional organizational skills with the ability to maintain accurate, complete, and audit-ready documentation across multiple concurrent workstreams.
• High attention to detail with strong analytical and problem-solving capabilities to evaluate data, identify patterns, and determine root causes of issues.
• Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight.
• Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally.
• Ability to maintain confidentiality and comply with HIPAA and all other privacy and data-security standards.
• Strong interpersonal skills and the ability to build positive, productive working relationships with co-workers, internal stakeholders, delegated entities, and external partners.
• Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work.
• Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook, and the ability to use these tools to analyze data, document audit findings, and support reporting needs.
• Working knowledge of medical terminology, electronic medical records (EMR), and case management systems.
• Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence.
• Proficient data-entry skills, including 10-key by touch, with a high degree of accuracy.
• Solid understanding of state and federal UM/CM requirements and managed-care operational frameworks.
• Required: Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN).

Benefits

• None specified