Senior Health Plan Compliance & Utilization Auditor

CommonSpirit Health

United States

Remote

USD 100,000 - 150,000

Full time

6 days ago

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Job summary

CommonSpirit Health seeks a Senior Compliance Specialist to lead the planning and implementation of a comprehensive monitoring and auditing program for health plan operations, including utilization management, quality assurance, and network management. You will partner with leadership to ensure adherence to CMS, DMHC, DHCS, and NCQA standards.

You will guide departments through audits, develop corrective action plans, and drive data-driven improvements.

Qualifications

Bachelor’s degree required; BSN preferred.
Minimum five years in managed healthcare/HMO utilization management, program operations compliance, or auditing.
Three+ years in Utilization Management auditing.
Deep knowledge of CMS, DMHC, DHCS, and NCQA accreditation.
Advanced skills in Google Workspace and data analysis.

Responsibilities

Direct the planning, development, and implementation of a monitoring and auditing program for health plan operations.
Oversee utilization management, quality, and network management compliance with federal and state laws.
Lead departments through regulatory audits and corrective action plans.
Provide strategic leadership and education on evolving regulatory requirements.
Collaborate across the organization to improve workflows and tools.