State Licensed Clinical Audit Specialist

Job Summary

State Licensed Clinical Audit Specialist, responsible for conducting full-time retrospective and focused audits of medical necessity determinations to ensure accuracy and compliance with regulations.

Key Responsibilities

• Conduct retrospective and targeted audits of utilization management medical necessity determinations
• Analyze audit findings to identify trends and provide recommendations for process improvement
• Collaborate with internal stakeholders to support compliance with regulatory standards and organizational goals

Required Qualifications, Training, and Education

• Associates of Science (A.S) in Nursing (ASN) required; Bachelor of Science (B.S) in Nursing (BSN) preferred
• Five (5) years of clinical or related healthcare industry experience required
• Two (2) years of Utilization Management/Utilization Review experience required
• Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
• MCG Certification(s) required or must be obtained within six (6) months of hire