Utilization Management Auditor

Licensed RN required Minimum 3 years of outpatient/inpatient clinical experience Minimum 3-5 years of experience in healthcare operations, Utilization Management, or auditing roles within health plans or managed care organizations In-depth knowledge of UM processes and evidence-based clinical guidelines (InterQual) Knowledge of Appeals & Grievances (A&G) process Experience with healthcare regulations and standards (e.g., CMS, state-specific guidelines, NCQA/URAQ) Proven track record in auditing and identifying process improvement areas Experience in developing and implementing reporting systems and documentation for audit activities Strong analytical and critical thinking skills Excellent attention to detail and accuracy Strong verbal and written communication skills Ability to work collaboratively across departments with a customer service-oriented approach Experience with audit management tools, healthcare payer operating systems, and MS Office Suite (Excel, Word, PowerPoint) Ability to manage multiple priorities and meet deadlines

Audit all stages of the UM process (intake, authorization creation, review, determination) Ensure UM processes comply with internal policies, regulatory guidelines, and industry best practices Conduct audits of authorization requests and reviews for accuracy and timeliness Monitor and audit intake and authorization workflows for optimization opportunities Evaluate workflows impacting Claims, Call Center, Appeals & Grievances (A&G), and other operational areas Identify systemic issues affecting multiple departments and recommend corrective actions Ensure cross-departmental communications and processes are streamlined Compile audit findings into detailed reports with observations and recommendations Maintain clear and accurate records of audit results and resolutions Ensure audits align with internal and external compliance requirements (CMS, state regulations, industry standards) Track and analyze audit outcomes for continuous improvement Collaborate with UM leadership and other departments to resolve audit findings Provide training and guidance to improve UM processes Stay informed of changes in healthcare regulations and best practices Recommend process improvements based on audit outcomes and trends