Utilization Management Auditor

CommonSpirit Health; United States; Remote; USD 100,000 - 150,000; Full time

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.

Skills

Interpersonal skills

Analytical thinking

Planning skills

Conflict resolution

Data analysis

Education

Bachelor's degree

Tools

Google Workspace

Job description

Where You’ll Work

Job Summary and Responsibilities

As our Senior Compliance Specialist, you will play a critical role in safeguarding organizational integrity by directing the planning, development, and implementation of a comprehensive monitoring and auditing program for contracted health plan operational functions, including utilization management, quality assurance, and network management. You will serve as a vital link between departmental leadership and regulatory bodies, ensuring that all health plan delegation oversight programs are executed with precision to support CommonSpirit Health’s commitment to departmental compliance and excellence.

Every day you will lead the execution of monitoring and auditing plans to assess the compliance of Utilization, Quality, and Network Management departments with Federal and State regulations, including CMS, DMHC, and DHCS requirements, as well as NCQA accreditation standards. Your work involves conducting rigorous reviews of policies, procedures, and case files, while proactively guiding departments through external audits and managing the execution of necessary corrective action plans to mitigate risk and strengthen internal controls.

To be successful in this role, you will leverage your expertise in managed healthcare and HMO operations to provide strategic leadership and business direction. You will act as a subject matter expert, supporting staff education on evolving legal requirements and recommending data-driven improvements to workflows and tools. By fostering collaborative relationships across the organization and representing CommonSpirit Health in industry regulatory collaboratives, you will drive a culture of continuous improvement and ensure sustained adherence to the highest standards of healthcare compliance.

• 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.

#Utilization Management, Managed Care, Health Plan Compliance, NCQA, Auditing, Delegation Oversight, CMS Regulations, Data Analysis

Job Requirements

• Education:Bachelor’s degree (BSN preferred).
• Experience: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 (Docs, Sheets, Slides) and data analysis.
• Soft Skills:Strong interpersonal, conflict resolution, analytical, and planning skills with a proven ability to communicate complex information to diverse audiences.