Clinical Audit Specialist – Utilization Management

CareSource

Clinical Audit Specialist responsible for auditing medical necessity determinations to ensure regulatory compliance. Collaborating with healthcare providers to enhance utilization management practices.

Posted 4/27/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $62,700 - $100,400 per yearWebsite

About the role

Key responsibilities & impact

Conduct retrospective and targeted audits of utilization management medical necessity determinations including pre-service, concurrent, and post service reviews.
Evaluate application of evidence-based clinical criteria (MCG, InterQual) and adherence to medical and administrative policies in utilization management determinations.
Assess clinical documentation, rationale for determinations, and compliance with regulatory and contractual and accreditation requirements.
Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making and utilization management processes.
Prepare comprehensive audit reports summarizing findings, identified risks, and recommendations for corrective action and process improvement to leadership.
Collaborate with Medical Directors, UM leadership and UM Operational teams to address complex audit findings.
Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.

Requirements

What you’ll need

Associates of Science (A.S) in Nursing (ASN) required
Bachelor of Science (B.S) in Nursing (BSN) preferred
Five (5) years of clinical or related healthcare industry experience required
Two (2) years Utilization Management/Utilization Review for Commercial, Medicaid, Medicare populations required
Demonstrated experience applying evidence-based criteria, including MCG and InterQual required
Managed Care experience required
Experience conducting retrospective reviews, quality audits, or compliance reviews preferred
Experience with analysis, data and reporting preferred

Benefits

Comp & perks

health insurance
retirement plans
paid time off
professional development
substantial and comprehensive total rewards package
bonus tied to company and individual performance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

utilization managementmedical necessity determinationsevidence-based clinical criteriaMCGInterQualclinical documentation assessmentaudit reportingdata analysisquality auditscompliance reviews

Soft Skills

collaborationcommunicationleadershipprocess improvementanalytical thinkingproblem-solvingattention to detailorganizational skillscritical thinkingrisk assessment

Certifications

Associates of Science in Nursing (ASN)Bachelor of Science in Nursing (BSN)