Senior Utilization Management Compliance Auditor

Dignity Health; Oregon; Hybrid; USD 120,000 - 150,000; Full time

Job summary

CommonSpirit Health in Oregon is seeking a Senior Compliance Specialist to lead the planning, development, and execution of a comprehensive monitoring and auditing program for contracted health plan operations, including utilization management, quality assurance, and network management.

You will serve as a regulatory liaison, ensure CMS, DMHC, DHCS and NCQA standards compliance, guide departments through external audits, and drive data-driven improvements while promoting a culture of healthcare

Qualifications

• Bachelor's degree required; BSN preferred.
• 5+ years in managed healthcare/HMO utilization management, program operations compliance, or auditing.
• 3+ years in Utilization Management Auditing.
• Deep knowledge of CMS, DMHC, DHCS, and NCQA accreditation standards.
• Advanced data analysis and ability to work with complex datasets.
• Strong interpersonal, conflict resolution, analytical, and planning skills.

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 thinking

Planning skills

Communication of complex information

Education

Bachelor's degree (BSN preferred)

Tools

Google Workspace

Job description

CommonSpirit Health in Oregon is seeking a Senior Compliance Specialist to lead the planning, development, and execution of a comprehensive monitoring and auditing program for contracted health plan operations, including utilization management, quality assurance, and network management.

You will serve as a regulatory liaison, ensure CMS, DMHC, DHCS and NCQA standards compliance, guide departments through external audits, and drive data-driven improvements while promoting a culture of healthcare