Risk Management Professional 2
New
United StatesFull-TimeMiddle
Salary$65,000 - $88,600 per year
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Job Details
- Required Skills
- Microsoft Power BIQuality Assurance
Requirements
- Active, unrestricted Registered Nurse (RN)
- Extensive experience in utilization management, clinical auditing, and/or quality assurance
- Strong knowledge of CMS, NCQA, and regulatory/accreditation requirements
- Deep understanding of clinical criteria and coverage guidelines (Medicare manuals, NCDs, LCDs, MCG, etc.)
- Demonstrated experience identifying audit risks, trends, and root causes
- Experience supporting or participating in regulatory program audits (CMS, NCQA)
- Strong analytical and critical thinking skills with ability to interpret and act on data
- Exceptional attention to detail and commitment to quality outcomes
- Ability to communicate complex findings clearly and influence stakeholders
- Prior experience in a dedicated auditor or quality oversight role preferred
- Experience working in healthcare environments across inpatient, outpatient, home health, and post-acute care preferred
- Familiarity with audit tracking tools, reporting systems, and dashboards preferred
Responsibilities
- Conduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policies
- Evaluate clinical decision-making and appropriate application of criteria across inpatient, outpatient, home health, and post-acute services
- Leverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areas
- Utilize Power Apps to support audit workflows, tracking, and data collection processes
- Analyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadership
- Perform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gaps
- Support program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness
- Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings
- Translate complex data into actionable insights and recommendations for stakeholders
- Present audit findings, risks, and trend analyses to leadership and cross-functional teams
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