Utilization Management Auditor (Must have RN / LVN license)

Alignment Health 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 experienced 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 Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Utilization Management Auditor (Must have RN / LVN License) ensures the accuracy, compliance, quality, and effectiveness of the Utilization Management (UM) processes within the health plan. This position audits all aspects of the UM lifecycle, including intake, authorization creation, clinical decision making, correspondence, documentation, timeliness, and audit-readiness. The auditor also evaluates processes impacting any of the above, as well as other departments such as claims, call centers, administrative & governance (A&G), and others to ensure that operations align with industry standards, regulatory requirements, and organizational policies. By identifying inefficiencies, gaps in compliance, quality issues, and opportunities for improvement, the Utilization Management Auditor supports the organization’s commitment to providing high-quality and cost-effective care while ensuring operational excellence.

This position builds and maintains strong collaborative partnerships with multiple key partners in the Clinical Services organization to identify, develop, implement, and monitor performance metrics related to UM Operations.

This position also builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external UM operations programs are well-coordinated and work cooperatively to achieve outcomes goals.

Job Duties/Responsibilities:

Audit Utilization Management (UM) Processes

• Review and assess all aspects of the UM lifecycle, including intake, authorization creation, clinical decision making, correspondence, documentation, timeliness, and audit-readiness to ensure they comply with internal policies, regulatory guidelines, and industry best practices.
• Conduct audits of organization determinations and reviews for accuracy, quality, completeness, and timely decision-making in accordance with applicable healthcare regulations and clinical guidelines.
• Monitor and audit workflows for intake and authorization activities to identify opportunities for optimization and efficiency improvements.

Audit Cross-Departmental Processes

• Identify systemic issues that may affect UM compliance or audit readiness and recommend corrective actions.
• Ensure that cross-departmental communications and processes are streamlined, accurate, and consistent with UM standards.

Reporting and Documentation

• Compile audit findings into detailed reports, outlining key observations, discrepancies, and areas of concern.
• Provide actionable recommendations for improving processes, resolving discrepancies, and ensuring compliance.
• Maintain clear and accurate records of audit results, follow-up actions, and resolutions.
• Contribute to developing, maintaining, and/or modifying audit tools

Compliance and Quality Assurance

• Ensure all audits align with internal and external compliance requirements, including CMS, state regulations, and industry standards.
• Track and analyze audit outcomes to ensure continuous improvement and adherence to best practices in UM.
• Actively participate in quality assurance activities to identify gaps and collaborate with leadership to address areas for improvement.

Collaboration and Stakeholder Engagement

• Work closely with Utilization Management leadership, Claims, A&G, and other operational departments to facilitate the resolution of audit findings and process improvements.
• Provide training, guidance, and feedback to departments and teams to improve UM processes and minimize errors.
• Act as a liaison between departments to ensure smooth coordination of UM and related operations.

Continuous Improvement and Training

• Stay informed of changes in healthcare regulations, industry standards, and best practices related to Utilization Management and healthcare operations.
• Recommend process improvements and best practices based on audit outcomes, industry trends, and new regulatory guidance.
• Support ongoing training efforts for UM staff and other departments impacted by audit results.

Job Requirements

Experience:

• 3-5 years of experience in Utilization Management and at least 1 year of experience in an auditing role within health plans or managed care organizations.
• Deep experience and working knowledge of NCDs, LCDs, and MCG
• In-depth knowledge of UM processes, including intake, authorization creation, and determination, as well as familiarity with cross-departmental functions like claims, A&G, and call center operations.
• Experience with healthcare regulations and standards (e.g., CMS, state-specific guidelines, NCQA) and their impact on utilization management.
• Proven track record in auditing and identifying areas for process improvement within a complex healthcare environment.
• Experience in developing and implementing reporting systems and documentation related to audit activities.

Education:

Required: Nursing degree

Preferred:

• Certification in Healthcare Compliance (CHC), Certified Professional in Utilization Review (CPUR), or similar certifications
• Additional certifications or training in auditing or healthcare quality improvement

Specialized Skills:

• Strong analytical and critical thinking skills, with the ability to identify patterns, discrepancies, and opportunities for improvement.
• Excellent attention to detail and the ability to maintain high levels of accuracy in all work products.
• Strong communication skills, both verbal and written, to present audit findings clearly and persuasively to stakeholders at all levels.
• Ability to work collaboratively across departments, with a customer service-oriented approach to problem-solving.
• Proficiency in using audit management tools, electronic health records (EHR) systems, and MS Office Suite (Excel, Word, PowerPoint).
• Knowledge of healthcare claims processing and call center operations is a plus.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.

Licensure:

Required: Valid US based nursing license (LVN/LPN or RN)

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform 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 reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $98,550.00 - $147,825.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, 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 Alignment Health’s talent acquisition team, please email careers@ahcusa.com.