Delegation Oversight Auditor, Case Management (LVN/RN Required)

Job not on LinkedIn

🔥 3 minutes ago

🇺🇸 United States – Remote

💵 $77.9k - $116.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• Conduct Utilization Management and Case Management audits in accordance with regulatory, contractual, and industry standards • Evaluate delegated entities’ compliance with CMS, contractual, and Alignment Healthcare UM/CM requirements • Maintain complete, organized, and audit-ready documentation • Execute audits using established methodologies, sampling criteria, and risk-based approaches • Communicate audit scope, expectations, timelines, documentation needs, findings, and corrective actions to delegated provider organizations • Present findings, explain root causes and performance gaps, and support delegates with corrective-action requirements • Review and validate Corrective Action Plans and evidence of remediation • Track CAP progress and complete follow-up activities through closure • Identify high-risk areas using historical results, monitoring data, clinical trends, and operational challenges • Recommend audit prioritization and refine audit scopes and schedules • Escalate emerging risks, irregular findings, systemic issues, and complex CAP matters to the Manager, Audit Administration • Prepare audit summaries, reports, dashboards, and materials for leadership, committees, regulators, and executives • Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other stakeholders • Manage multiple concurrent audits and support training, education, regulatory audit preparation, and special projects

🎯 Requirements

• 3-5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of clinical operations of managed care operations • Prior Medicare Managed Care UM/CM experience related to delegation oversight and auditing • 1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers • Demonstrable detailed knowledge/experience with CMS, HICE, or related UM/CM requirements • Required: Bachelor’s Degree in nursing or equivalent • Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing UM/CM • Exceptional organizational skills with the ability to maintain accurate, complete, and audit-ready documentation across multiple concurrent workstreams • High attention to detail with strong analytical and problem-solving capabilities to evaluate data, identify patterns, and determine root causes of issues • Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight • Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally • Ability to maintain confidentiality and comply with HIPAA and all other privacy and data-security standards • Strong interpersonal skills and the ability to build positive, productive working relationships with co-workers, internal stakeholders, delegated entities, and external partners • Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work • Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook • Working knowledge of medical terminology, electronic medical records (EMR), and case management systems • Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence • Proficient data-entry skills, including 10-key by touch, with a high degree of accuracy • Solid understanding of state and federal UM/CM requirements and managed-care operational frameworks • Required: Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN)