The Utilization Management Auditor is responsible for overseeing and auditing the work performed by the Third-Party Administrator (TPA) related to pre-certifications. This role ensures that the TPA’s pre-certification processes align with the health plan’s policies, regulatory requirements, and industry standards. The UR Auditor will conduct regular reviews, identify discrepancies, recommend improvements, and collaborate with the TPA and internal stakeholders to ensure the efficiency and accuracy of the pre-certification process.
Primary Duties and Responsibilities:
- Audit Pre-Certification Activities: Review and audit pre-certification requests and decisions made by the TPA to ensure they meet regulatory guidelines and company policies.
- Identify Process Improvements: Analyze TPA performance, identify areas for improvement, and provide feedback and recommendations to enhance the accuracy and efficiency of the pre-certification process.
- Compliance Monitoring: Ensure that pre-certification activities comply with all relevant healthcare regulations, including CMS guidelines, and any contractual obligations with the TPA.
- Reporting: Compile and present detailed audit reports to internal leadership, highlighting trends, compliance issues, and recommendations for process improvements.
- Collaboration: Work closely with the TPA, internal operations teams, and medical management to resolve issues, ensure accurate data reporting, and drive best practices in pre-certification.
- Training and Education: Provide training to internal teams and the TPA as needed to improve understanding and compliance with pre-certification requirements.
- Manage Documentation: Ensure all audit findings, recommendations, and resolutions are documented and tracked for follow-up.
- Track Metrics: Monitor key performance indicators (KPIs) related to pre-certification to evaluate TPA performance and identify areas for improvement.
Qualifications
- Bachelor’s degree in healthcare, business, or related field (or equivalent experience).
- 3-5 years of experience in Utilization Management or related healthcare audit roles.
- Strong knowledge of pre-certification processes, medical necessity guidelines, and regulatory requirements (e.g., CMS, ACA, state regulations).
- Experience auditing third-party administrator processes and ensuring compliance with contractual obligations.
- Excellent analytical, problem-solving, and critical thinking skills.
- Strong communication skills, with the ability to present findings to senior leadership and collaborate across departments.
- Detail-oriented with the ability to manage multiple tasks and meet deadlines.
Skills and Competencies
- Audit and Compliance: In-depth understanding of auditing processes, including knowledge of medical coding, claims review, and regulatory compliance.
- Data Analysis: Ability to analyze data, identify trends, and make data-driven decisions.
- Problem Solving: Ability to address issues proactively and resolve conflicts between internal teams and TPAs.
- Technical Proficiency: Familiarity with healthcare management software, auditing tools, and Microsoft Office Suite (Excel, Word, PowerPoint).
- Collaboration and Communication: Strong interpersonal skills with the ability to build relationships and work collaboratively with external partners and internal teams.
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