Auditor, Delegate UM/CM
Alignment Health
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $77,905 - $116,858 per year
About the role
- Conduct UM/CM audits in accordance with regulatory, contractual, and industry standards
- Execute Utilization Management (UM) and Case Management (CM) audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
- Evaluate delegated entities’ compliance with CMS and contractual requirements, and Alignment Healthcare’s UM/CM policies and standards.
- Maintain organized, complete, and audit‑ready documentation to support regulatory, accreditation, and internal oversight reviews.
Requirements
- 3-5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of clinical operations of managed care operations.
- Prior Medicare Managed Care UM/CM experience related to delegation oversight and auditing.
- 1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers.
- Demonstrable detailed knowledge/experience with CMS, HICE, or related UM/CM requirements.
- Required: Bachelor’s Degree in nursing or equivalent.
- Preferred: Master’s degree in nursing or related fields (e.g., MHA, MPH, MBA, MSN).
Benefits
- Health insurance
- 401(k) matching
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Utilization Management (UM)Case Management (CM)auditingcompliance evaluationdocumentation standardssampling criteriaclinical operationsoversight auditsMedicare Managed Caredelegation oversight
Soft Skills
organizational skillsattention to detailanalytical skillscommunication skillsregulatory readiness
Certifications
Bachelor’s Degree in nursingMaster’s degree in nursingMaster’s in Healthcare Administration (MHA)Master’s in Public Health (MPH)Master’s in Business Administration (MBA)Master’s in Nursing (MSN)