Utilization Management Auditor

Job Overview

The Utilization Management (UM) Auditor is responsible for conducting thorough audits of utilization review activities within a payer environment to ensure compliance with medical necessity criteria, regulatory standards, and payer policies. This role focuses exclusively on auditing UM processes and decisions to identify gaps, ensure accuracy, and support continuous quality improvement without involvement in training or education.

This role ensures the integrity and accuracy of UM decisions by providing objective, data-driven audit insights that support compliance, quality improvement, and operational excellence within the payer organization. The UM Auditor helps safeguard member outcomes and payer integrity through rigorous review and feedback mechanisms.

Essential functions:

• Perform detailed audits of prior authorization, concurrent review, inpatient/observation, and post-acute care utilization decisions.
• Evaluate adherence to medical necessity criteria (e.g., MCG, InterQual), payer policies, and regulatory requirements.
• Identify documentation deficiencies, compliance risks, and opportunities for process improvement.
• Collaborate with UM leadership and Medical Directors to communicate audit findings and recommend corrective actions.
• Support interrater reliability (IRR) initiatives by providing objective audit data and feedback.
• Prepare audit reports, dashboards, and summaries for operational stakeholders.
• Monitor trends in audit results to identify systemic issues and support quality improvement projects.
• Maintain up-to-date knowledge of UM guidelines, payer policies, and regulatory changes impacting audit criteria.

Competencies:

• Clinical judgment and UM expertise
• Analytical and audit skills
• Regulatory and compliance literacy
• Data-driven quality assessment
• Effective communication and collaboration
• Attention to detail and documentation accuracy

Required education and experience:

• Bachelor’s or Master’s degree in Nursing, Healthcare Administration, Public Health, or related field required.
• 3–5+ years of Utilization Management experience within a payer or managed care environment.
• Strong knowledge of medical necessity criteria (MCG, InterQual), CMS guidelines, and payer authorization processes.
• 2+ years of experience conducting audits or quality reviews in UM or clinical settings.
• Excellent analytical, communication, and reporting skills.
• Clinical (active and unrestricted) licensure (e.g., RN) required.
• 5–10+ years of experience in a clinical setting.
• Experience with healthcare technology (e.g., EHR systems like Epic or Cerner, clinical decision support).

Preferred education, certifications and/or experience:

• Familiarity with UM systems (e.g., GuidingCare, TruCare, Jiva, Epic UM modules).
• Experience with NCQA/URAC accreditation standards and audit methodologies.
• Background in quality improvement, compliance, or regulatory affairs.
• Prior audit experience within a managed care or health plan setting preferred.
• Experience with value-based care models, ACOs, or population health strategies.
• Certification in Lean Six Sigma, PMP, or healthcare quality (e.g., CPHQ).

Physical Requirements/Work environment:

• Remote role with occasional travel (Less than 5%)
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.
• Must have home office, mobile phone, computer with security requirements met.
• Internet Speed Minimum of 100 Mbps download and 10–20 Mbps upload
• Typing/data entry of 30 WPM

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without advanced notice.

Pay: From $48.00 per hour

Experience:

• Utilization Managment: 3 years (Required)
• conducting audits or quality reviews: 2 years (Required)

License/Certification:

• RN License (Required)

Work Location: Remote