State Licensed Auditor, UM​/CM

A company is looking for an Auditor, Delegate UM/CM.

Key Responsibilities Conduct Utilization Management (UM) and Case Management (CM) audits to ensure compliance with regulatory and contractual standards Engage with delegated provider organizations to communicate findings and facilitate corrective actions for performance improvement Prepare audit reports and summaries that highlight compliance gaps and operational issues across UM/CM functions

Required Qualifications 3-5 years of experience in Utilization and Case Management in an HMO, Medicare Advantage, or IPA setting Prior experience conducting oversight audits of delegated entities and/or ancillary providers Bachelor's Degree in nursing or equivalent;
Master's degree preferred Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN) Strong knowledge of Medicare audit processes and applicable regulatory requirements governing UM/CM