Alignment Health · 13 hours ago
Auditor, Delegate UM/CM
United States
Full-time
Onsite
Mid Level
$78K/yr - $117K/yr
3+ years expAlignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. The Auditor, Delegate UM/CM plays a critical role in supporting Alignment Healthcare’s delegated oversight audit program by conducting Utilization Management (UM) and Case Management (CM) audits to ensure compliance with regulatory and operational expectations.
Medical DeviceHealthcareWellnessHospitalHealth CareMedical
Responsibilities
Conduct UM/CM audits in accordance with regulatory, contractual, and industry standards
Execute Utilization Management (UM) and Case Management (CM) audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness
Evaluate delegated entities’ compliance with CMS and contractual requirements, and Alignment Healthcare’s UM/CM policies and standards
Maintain organized, complete, and audit‑ready documentation to support regulatory, accreditation, and internal oversight reviews
Ensure all audit activities align with the enterprise audit strategy and risk‑based approach established by the Manager, Audit Administration
Engage delegated provider organizations to correct deficiencies and improve performance
Communicate audit scope, expectations, timelines, required documentation, and process steps clearly to delegated entities throughout the audit lifecycle
Present audit findings to delegates, explaining root causes, performance gaps, non‑compliance risks, and potential operational impacts related to UM/CM processes
Support delegated entities in understanding UM/CM compliance requirements and expectations for corrective actions
Foster professional, collaborative relationships to promote transparent discussions, accountability, and continuous improvement
Perform risk assessment and prioritize UM/CM audits
Contribute to identifying high‑risk areas by reviewing historical audit results, monitoring data, clinical performance trends, and operational challenges related to UM/CM
Recommend prioritization of UM/CM audits based on severity of risk, regulatory sensitivity, and emerging compliance or clinical performance trends
Provide input to refine audit scopes and schedules in alignment with the Manager’s risk‑based UM/CM audit strategy
Escalate emerging UM/CM‑related risks, irregular findings, or potential systemic issues to the Manager for strategic review and future audit planning
Validate corrective actions for UM/CM compliance
Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses UM/CM deficiencies identified during audits
Assess evidence including revised workflows, updated clinical review criteria, policy changes, revised documentation, and utilization management decision processes
Track CAP progress and ensure follow‑up activities are completed, documented, and closed in accordance with departmental requirements
Escalate irregular, stalled, or complex CAP issues to the Manager, Audit Administration for higher‑level intervention
Report UM/CM audit findings to facilitate organizational awareness
Prepare clear, concise, and well‑structured audit summaries that highlight key risks, compliance gaps, operational issues, and improvement opportunities across UM/CM delegated functions
Contribute to audit reporting tools, dashboards, and documentation used for internal leadership, cross‑functional teams, and enterprise oversight groups
Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal stakeholders to ensure findings are understood, actionable, and integrated into broader performance improvement efforts
Support preparation of audit materials and evidence for internal committees, external regulatory bodies, and executive‑level oversight forums
Manage multiple UM/CM audits concurrently, ensuring adherence to established timelines, quality standards, and documentation requirements
Monitor UM/CM operational, clinical, and compliance data to identify emerging issues requiring targeted audit review
Support the development and delivery of training and education for delegated entities on UM/CM standards, audit expectations, and compliance requirements
Assist in preparing documentation and evidence for CMS or other regulatory audits
Perform additional responsibilities and special projects as assigned
Qualification
Required
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
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, and the ability to use these tools to analyze data, document audit findings, and support reporting needs
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
Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN)
Preferred
Master's degree in nursing or related fields (e.g., MHA, MPH, MBA, MSN)
Company
Alignment Health
Alignment Health provides eldercare services.
501-1000 employees
Funding
Current Stage
Public CompanyTotal Funding
$696.05MKey Investors
K2 HealthVenturesWarburg PincusGeneral Atlantic
2024-11-15Post Ipo Debt· $321.05M
2024-01-09Private Equity
2021-03-26IPO
Leadership Team
Dawn Maroney
President, Markets & CEO of Alignment Health Plan
John Kao
CEO and Founder
Recent News
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