Risk Management Professional ; Licensed Nurse

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The Risk Management Professional 2 is responsible for leading and executing quality audits within the Center Well Utilization Management (UM) program, ensuring compliance with regulatory requirements, including CMS and NCQA standards.

This role is heavily focused on audit accuracy, data analysis, and identification of risks and trends, with an emphasis on leveraging Power BI and Power Apps to support audit processes, reporting, and performance monitoring.

The successful candidate will bring deep expertise in clinical criteria and regulatory guidance (e.g., Medicare Manuals, NCDs, LCDs, coverage policies, MCG) and demonstrate a strong passion for quality and continuous improvement. This role requires the ability to translate audit findings into meaningful insights, identify root causes, and support program audit readiness from a clinical and research-based perspective.

An active, unrestricted Registered Nurse (RN) is required.

• Conduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policies
• Evaluate clinical decision‑making and appropriate application of criteria across inpatient, outpatient, home health, and post‑acute services
• Leverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areas
• Utilize Power Apps to support audit workflows, tracking, and data collection processes
• Analyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadership
• Perform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gaps
• Demonstrate strong familiarity with clinical criteria sources, including Medicare Manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), plan coverage policies, and MCG guidelines
• Support program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness from a regulatory and research‑based perspective
• Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings
• Demonstrate a high level of attention to detail and a strong commitment to quality and accuracy
• Translate complex data into actionable insights and recommendations for stakeholders
• Present audit findings, risks, and trend analyses confidently to leadership and cross‑functional teams

• Active, unrestricted Registered Nurse (RN)
• Extensive experience in utilization management, clinical auditing, and/or quality assurance
• Strong knowledge of CMS, NCQA, and regulatory/accreditation requirements
• Deep understanding of clinical criteria and coverage guidelines (Medicare manuals, NCDs, LCDs, MCG, etc.)
• Demonstrated experience identifying audit risks, trends, and root causes
• Experience supporting or participating in regulatory program audits (CMS, NCQA)
• Strong analytical and critical thinking skills with ability to interpret and act on data
• Exceptional attention to detail and commitment to quality outcomes
• Ability to communicate complex findings clearly and influence stakeholders

• Prior experience in a dedicated auditor or quality oversight role
• Experience working in healthcare environments across inpatient, outpatient, home health, and post‑acute care
• Familiarity with audit tracking tools, reporting systems, and dashboards
• Experience translating data into reporting and insights

Employees must provide their own internet service meeting a minimum download speed of 25 Mbps and an upload speed of 10 Mbps, with wireless, wired cable or DSL connection suggested. In certain roles the minimum recommended internet speed may need to be upgraded by the company. A dedicated space that minimizes interruptions is required to protect member PHI / HIPAA information. Occasional travel to company offices for training or meetings may be required.

Scheduled weekly hours: 40 hours

Pay range: $65,000 - $88,600 per year

This position is eligible for a bonus incentive plan based on company and/or…