Utilization Management Auditor

Job Description

Job Description

COMPANY OVERVIEW :

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE AND SCOPE :

The Utilization Management Auditor plays a critical role in ensuring the accuracy, compliance, and effectiveness of the Utilization Management (UM) processes within the health plan. This position is responsible for auditing the results of the full UM lifecycle, including intake, authorization creation, and authorization review and determination. The auditor also evaluates processes impacting other departments such as claims, call centers, appeals and grievances (A&G), and others to ensure that operations align with industry standards, regulatory requirements, and organizational policies. By identifying inefficiencies, gaps in compliance, and opportunities for improvement, the Utilization Management Auditor supports the organization's commitment to providing high-quality and cost-effective care while ensuring operational excellence.

PRINCIPAL RESPONSIBILITIES AND DUTIES :

Audit Utilization Management (UM) Processes

Review and assess all stages of the UM process, including intake, authorization creation, authorization review, and determination, to ensure they comply with internal policies, regulatory guidelines, and industry best practices.

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.

Audit Cross-Departmental Processes

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.

Reporting and Documentation

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.

Compliance and Quality Assurance

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.

Actively participate in quality assurance activities to identify gaps and collaborate with leadership to address areas for improvement.

Collaboration and Stakeholder Engagement

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.

Continuous Improvement and Training

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.

EDUCATION, EXPERIENCE AND REQUIRED SKILLS :

Licensed RN is required.

Additional certifications or training in auditing or healthcare quality improvement is a plus.

Experience

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) and their impact on utilization management.

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.

Required Skills

Strong analytical and critical thinking skills, with the ability to identify patterns, discrepancies, and opportunities for improvement.

Excellent attention to detail and the ability to maintain high levels of accuracy in all work products.

Strong communication skills, both verbal and written, to present audit findings clearly and persuasively to stakeholders at all levels.

Ability to work collaboratively across departments, with a customer service-oriented approach to problem-solving.

Experience with developing, using, & 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.