Clinical Audit Support Specialist
Alignment Health
part-time
Posted on:
Location Type: Remote
Location: Oregon • United States
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Salary
💰 $91,651 - $137,477 per year
About the role
- 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
- Conduct audits of organization determinations and reviews for accuracy, quality, completeness, and timely decision-making
- Monitor and audit workflows for intake and authorization activities
- Identify systemic issues that may affect UM compliance or audit readiness and recommend corrective actions
- Compile audit findings into detailed reports and provide actionable recommendations for improving processes
- Maintain clear and accurate records of audit results
- Ensure all audits align with internal and external compliance requirements
Requirements
- 3-5 years of experience in Utilization Management
- 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
- 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)
- 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
- Nursing degree
- Certification in Healthcare Compliance (CHC), Certified Professional in Utilization Review (CPUR), or similar certifications preferred
- Additional certifications or training in auditing or healthcare quality improvement.
Benefits
- Health insurance
- Flexible work arrangements
- Professional development
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
auditingUtilization Managementclinical decision makingreporting systemsdocumentationprocess improvementhealthcare regulationsNCDsLCDsMCG
Soft Skills
analytical skillsattention to detailcommunicationproblem-solvingorganizational skills
Certifications
Healthcare Compliance (CHC)Certified Professional in Utilization Review (CPUR)