Senior Utilization Management Auditor – Compliance & QA

CommonSpirit Health; Rancho Cordova (CA); On-site; USD 110,000 - 160,000; Full time

Job summary

CommonSpirit Health seeks a Senior Compliance Specialist to direct the planning, development, and implementation of a comprehensive monitoring and auditing program for health plan operations, including utilization management, quality assurance, and network management.

You will lead reviews against Federal and State requirements (CMS, DMHC, DHCS) and NCQA standards, guide corrective actions, and partner with leadership to strengthen internal controls and support a culture of continuous compliance.

Qualifications

• Bachelor’s degree; BSN preferred.
• Minimum five (5) years of experience in managed healthcare/HMO utilization management, program operations compliance, or auditing.
• Utilization Management: Minimum three (3) years of specific experience in Utilization Management Auditing.
• Regulatory Knowledge: Deep understanding of federal and state laws (CMS, DMHC, DHCS) and NCQA accreditation standards.
• Technical Proficiency: Advanced skills in Google Workspace and data analysis.
• Soft Skills: Strong interpersonal, conflict resolution, analytical, and planning skills with a proven ability to communicate complex information to diverse audiences.

Responsibilities

• Direct the planning, development, and implementation of a robust monitoring and auditing program for health plan operational functions.
• Oversee utilization management, quality, and network management compliance across the organization.
• Execute health plan delegation oversight programs to support CommonSpirit Health’s departmental compliance objectives.
• Develop and implement audit plans to assess compliance with Federal and State laws, regulations, and accreditation standards.
• Guide departments through Health Plan and State audits, ensuring the successful execution of corrective action plans.
• Provide leadership and business direction to Corporate Responsibility and Operations teams regarding regulatory requirements.

Skills

Interpersonal skills

Analytical skills

Planning

Conflict resolution

Communication

Education

Bachelor’s degree (BSN preferred)

Tools

Google Workspace

Job description

CommonSpirit Health seeks a Senior Compliance Specialist to direct the planning, development, and implementation of a comprehensive monitoring and auditing program for health plan operations, including utilization management, quality assurance, and network management.

You will lead reviews against Federal and State requirements (CMS, DMHC, DHCS) and NCQA standards, guide corrective actions, and partner with leadership to strengthen internal controls and support a culture of continuous compliance.