State Licensed Auditor, UM/CM

Job Summary

A company is looking for an Auditor, Delegate UM/CM.

Key Responsibilities

• Conduct Utilization Management (UM) and Case Management (CM) audits to ensure compliance with regulatory and contractual standards
• Engage with delegated provider organizations to communicate findings and facilitate corrective actions for performance improvement
• Prepare audit reports and summaries that highlight compliance gaps and operational issues across UM/CM functions

Required Qualifications

• 3-5 years of experience in Utilization and Case Management in an HMO, Medicare Advantage, or IPA setting
• Prior experience conducting oversight audits of delegated entities and/or ancillary providers
• Bachelor's Degree in nursing or equivalent; Master's degree preferred
• Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN)
• Strong knowledge of Medicare audit processes and applicable regulatory requirements governing UM/CM