Remote Auditor, Delegate Utilization/Case Management

R1638 reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really matters, not only changing lives but saving them. Together. Remote ---The Auditor, Delegate UM/CM plays a critical role in supporting reputed company’s delegated reputed company audit program by conducting Utilization Management (UM) and Case Management (CM) audits to ensure delegated entities meet regulatory, contractual, and operational expectations. Working under the guidance of the Manager, Audit Administration, the Auditor executes risk‑based audits using established methodologies, documentation standards, and evaluative criteria that align with the enterprise audit strategy. In this role, the Auditor evaluates delegated UM and CM operations for compliance with CMS and contractual requirements, as well as reputed company’s policies and standards. The Auditor leads audit activities from planning through reporting, synthesizing findings that identify root causes, performance gaps, and opportunities for improvement. Audit documentation is maintained to support regulatory readiness and internal reputed company processes. The Auditor also serves as a key liaison to delegated provider organizations, facilitating clear and constructive communication throughout the audit lifecycle. The role supports delegates in understanding findings and required corrective actions, escalating reputed company or irregular issues to the Manager, Audit Administration for review and resolution. Through effective execution of UM/CM audits, strong cross‑functional collaboration, and adherence to audit‑ready documentation standards, the Auditor supports reputed company’s transformation toward a more proactive, data‑driven reputed company model and contributes to improved quality, compliance, and performance outcomes across delegated clinical functions. Job Duties/Responsibilities 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 reputed company’s UM/CM policies and standards.
• Maintain organized, complete, and audit‑ready documentation to support regulatory, accreditation, and internal reputed company reviews.
• Ensure reputed company 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 reputed company 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 reputed company improvement. reputed company 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 reputed company 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‑reputed company 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 reputed company and ensure follow‑up activities are completed, documented, and closed in accordance with departmental requirements.
• Escalate irregular, stalled, or reputed company CAP issues to the Manager, Audit Administration for higher‑level reputed company. Report UM/CM audit findings to facilitate organizational awareness
• Prepare clear, concise, and well‑structured audit summaries that reputed company 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 reputed company 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 reputed company forums. Additional Responsibilities
• 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.
• reputed company additional responsibilities and special projects as assigned. Job Requirements Experience
• 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 reputed company to delegation reputed company and auditing.
• 1-2 years minimum experience conducting reputed company audits of delegated entities and/or ancillary providers
• Demonstrable detailed knowledge/experience with CMS, HICE, or reputed company UM/CM requirements. Education
• Required Bachelor’s Degree in nursing or equivalent
• Preferred Master’s degree in nursing or reputed company fields (e.g., MHA, MPH, MBA, MSN) Training
• Required None
• Preferred None Specialized Skills
• 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 reputed company 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 reputed company.
• 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 reputed company with HIPAA and reputed company other privacy and data‑reputed company 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 reputed company Office applications, especially reputed company, 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 reputed company, 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. Licensure
• Required Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN). Other
• Required None Essential Physical Functions The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include reputed company vision and the ability to adjust focus. Pay Range $77,905.00 - $116,858.00Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. reputed company is an Equal Opportunity/Affirmative Action Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation.
• DISCLAIMER Please beware of recruitment phishing scams affecting reputed company and other employers where individuals receive fraudulent employment-reputed company offers in exchange for money or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit card, send you a reputed company, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https//reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of reputed company’s reputed company team, please email [email protected]. Apply tot his job Apply To this Job

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