Delegation Oversight Auditor, Case Management (LVN/RN Required)

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform audits for Utilization Management and Case Management in line with regulatory, contractual, and industry standards.

• Assess compliance of delegated entities with CMS, contractual obligations, and Alignment Healthcare's UM/CM standards.

• Ensure comprehensive, organized, and audit-ready documentation is maintained.

• Conduct audits utilizing established methodologies, sampling criteria, and a risk-based approach.

• Clearly communicate the audit scope, expectations, timelines, documentation requirements, findings, and corrective actions to delegated provider organizations.

• Present audit findings, elucidate root causes and performance gaps, and assist delegates with the requirements for corrective actions.

• Review and authenticate Corrective Action Plans and evidence of remediation.

• Monitor CAP progress and perform follow-up activities until closure.

• Identify high-risk areas by analyzing historical results, monitoring data, clinical trends, and operational challenges.

• Suggest audit prioritization and refine the scopes and schedules of audits.

• Raise concerns regarding emerging risks, irregular findings, systemic issues, and complex CAP matters to the Manager of Audit Administration.

• Compile audit summaries, reports, dashboards, and materials for leadership, committees, regulators, and executives.

• Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other relevant stakeholders.

• Oversee multiple simultaneous audits and assist with training, education, regulatory audit preparation, and special projects.

⛳️ Requirements

• 3-5 years of experience in Utilization and Case Management within an HMO, Medicare Advantage, and/or IPA environment, with comprehensive knowledge of clinical operations in managed care.

• Previous experience in Medicare Managed Care UM/CM related to delegation oversight and auditing.

• A minimum of 1-2 years of experience conducting oversight audits of delegated entities and/or ancillary providers.

• Proven detailed knowledge and experience with CMS, HICE, or related UM/CM regulations.

• Required: Bachelor’s Degree in nursing or an equivalent field.

• In-depth understanding of Medicare audit procedures and relevant state and federal regulatory standards governing UM/CM.

• Excellent organizational skills with the capability to maintain precise, complete, and audit-ready documentation across various concurrent tasks.

• Keen attention to detail with strong analytical and problem-solving skills to assess data, recognize patterns, and determine root causes of issues.

• Demonstrated ability to take initiative, manage priorities, and complete tasks on time with minimal supervision.

• Superior verbal and written communication skills, with the ability to articulate audit findings, expectations, and technical information in a clear and professional manner.

• Capacity to uphold confidentiality and adhere to HIPAA and other privacy and data-security standards.

• Strong interpersonal skills and the ability to foster positive, productive relationships with colleagues, internal stakeholders, delegated entities, and external partners.

• Proficient mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as required during audits.

• Advanced proficiency in Microsoft Office applications, particularly Excel, Word, PowerPoint, and Outlook.

• Familiarity with medical terminology, electronic medical records (EMR), and case management systems.

• Ability to accurately follow instructions, maintain data integrity, and apply sound judgment in evaluating audit evidence.

• Competent data-entry skills, including 10-key by touch, with a high level of accuracy.

• Solid understanding of state and federal UM/CM regulations and managed-care operational frameworks.

• Required: Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN).

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and career advancement.

• Flexible work environment with a focus on work-life balance.