Utilization Management Auditor

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September 19

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HealthAxis Group

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Healthcare Insurance • SaaS • Fintech

HealthAxis Group is a technology solutions provider specializing in healthcare administration. Their cloud-native platform, AxisCore™, streamlines health plan management through solutions like claims processing and benefit administration, designed to enhance operational efficiency. HealthAxis offers a suite of services including Business Process as a Service (BPaaS), consulting, and staff augmentation. The company's approach focuses on scalability, compliance, and tailored support, aiming to empower healthcare organizations to meet member needs effectively.

201 - 500 employees

Founded 1965

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

📋 Description

• Review and assess all stages of the Utilization Management (UM) process, including intake, authorization creation, authorization review, and determination. • Conduct audits of authorization requests and reviews for accuracy, completeness, and timely decision-making in accordance with applicable healthcare regulations. • Monitor and audit workflows for intake and authorization activities to identify opportunities for optimization and efficiency improvements. • Evaluate workflows and tickets impacting other departments such as Claims, Call Center, Appeals and Grievances (A&G), and other operational areas. • Identify systemic issues that may affect multiple departments and recommend corrective actions. • Ensure that cross-departmental communications and processes are streamlined, accurate, and consistent with UM standards. • Compile audit findings into detailed reports, outlining key observations, discrepancies, and areas of concern. • Provide actionable recommendations for improving processes, resolving discrepancies, and ensuring compliance. • Maintain clear and accurate records of audit results, follow-up actions, and resolutions. • Ensure all audits align with internal and external compliance requirements, including CMS, state regulations, and industry standards. • Track and analyze audit outcomes to ensure continuous improvement and adherence to best practices in UM. • Participate in quality assurance activities to identify gaps and collaborate with leadership to address areas for improvement. • Work closely with Utilization Management leadership, Claims, A&G, and other operational departments to facilitate the resolution of audit findings and process improvements. • Provide training, guidance, and feedback to departments and teams to improve UM processes and minimize errors. • Act as a liaison between departments to ensure smooth coordination of UM and related operations. • Stay informed of changes in healthcare regulations, industry standards, and best practices related to Utilization Management and healthcare operations. • Recommend process improvements and best practices based on audit outcomes, industry trends, and new regulatory guidance. • Support ongoing training efforts for UM staff and other departments impacted by audit results.

🎯 Requirements

• Licensed RN is required. • Additional certifications or training in auditing or healthcare quality improvement is a plus. • Minimum of 3 years of outpatient/inpatient clinical experience. • Minimum of 3-5 years of experience in healthcare operations, Utilization Management, or auditing roles within health plans or managed care organizations. • In-depth knowledge of UM processes, including intake and the use of evidence based clinical guidelines (InterQual). • Knowledge of Appeals & Grievances (A&G) process is helpful. • Experience with healthcare regulations and standards (e.g., CMS, state-specific guidelines, NCQA/URAQ). • Proven track record in auditing and identifying areas for process improvement within a complex healthcare environment. • Experience in developing and implementing reporting systems and documentation related to audit activities. • Strong analytical and critical thinking skills. • Excellent attention to detail and accuracy. • Strong verbal and written communication skills. • Ability to work collaboratively across departments. • Experience with developing, using, and optimizing audit management tools, healthcare payer operating systems, and MS Office Suite (Excel, Word, PowerPoint). • Ability to manage multiple priorities and meet deadlines in a fast-paced environment. • Must be legally eligible to work in the United States without sponsorship. • Must be able to provide high-speed internet, a quiet and private place to work, a desk, and a chair as a remote employee. • Willingness to undergo a background check, including drug test, in accordance with local laws/regulations. • Must be 18 years of age or older.