Job Summary:The Clinical Audit Specialist - Utilization Management is responsible for conducting retrospective and focused audits of medical necessity determinations to ensure accuracy, regulatory compliance, and alignment with evidence-based clinical criteria. This role serves as a subject matter expert in medical necessity criteria to evaluate utilization management decisions across physical and/or behavioral health services and provide recommendations to improve consistency while ensuring adherence to state, federal, accreditation, and organizational requirements.
Essential Functions:- Conduct retrospective and targeted audits of utilization management medical necessity determinations including pre-service, concurrent, and post service reviews.
- Evaluate application of evidence-based clinical criteria (MCG, InterQual) and adherence to medical and administrative policies in utilization management determinations.
- Assess clinical documentation, rationale for determinations, and compliance with regulatory and contractual and accreditation requirements.
- Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making and utilization management processes.
- Prepare comprehensive audit reports summarizing findings, identified risks, and recommendations for corrective action and process improvement to leadership.
- Collaborate with Medical Directors, UM leadership and UM Operational teams to address complex audit findings.
- Provide support for internal and external audit readiness by collaborating with UM Operations to ensure compliance with state, federal, CMS and accreditation standards.
- Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.
- Maintain current knowledge of regulatory requirements, clinical guidelines, and organizational policies impacting utilization management and audit practices.
- Conduct independent research and analysis to identify opportunities for improvement and recommend evidence-based solutions.
- Work collaboratively with internal stakeholders to support organizational goals and quality improvement initiatives.
- Perform any other job related duties as requested.
Education and Experience:- Associates of Science (A.S) in Nursing (ASN) required
- Bachelor of Science (B.S) in Nursing (BSN) preferred
- Five (5) years of clinical or related healthcare industry experience required
- Two (2) years Utilization Management/Utilization Review for Commercial, Medicaid, Medicare populations required
- Demonstrated experience applying evidence-based criteria, including MCG and InterQual required
- Managed Care experience required
- Experience conducting retrospective reviews, quality audits, or compliance reviews preferred
- Experience with analysis, data and reporting preferred
Competencies, Knowledge and Skills:- Advanced knowledge of medical necessity review process
- Strong proficiency in application and interpretation of evidence-based criteria
- Understanding of Medicaid, Medicare, and/or Commercial regulatory requirements
- Ability to analyze complex clinical documentation and identify risk exposure
- Proficient in navigational and data entry skills, Microsoft Outlook, Word, Excel
- Strong communication and collaboration skills- oral and written, professional and respectful
- Ability to exercise independent and sound judgment in decision making with a high level of critical thinking
- Detailed-oriented with strong analytical skills
- Excellent organizational and time management skills
- Ability to manage multiple priorities concurrently
- Excellent follow-through skills and attention to detail
- Culturally competent, member centric, and customer focused
- Proper grammar usage and phone etiquette
- Exhibits change resiliency
Licensure and Certification:- Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
- Multi state licensure required within 6 months of hire, if offered in home state
- MCG Certification(s) is required or must be obtained within six (6) months of hire
Working Conditions:- General office environment; may be required to sit or stand for extended periods of time
- May be required to work additional hours and/or outside normal business hours as needed to meet deadlines.
- Travel is not typically required
Compensation Range:
$62,700.00 - $100,400.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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