Senior Utilization Management Audit & Compliance Analyst

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Senior Utilization Management Audit & Compliance Analyst based in the United States.

This role serves as a subject matter expert for external customer audits, regulatory inquiries, and utilization management oversight activities. You will analyze complex UM data, investigate findings, and prepare accurate, evidence-based responses for health plans, clients, regulators, and accreditation organizations. The position combines healthcare operations expertise with advanced data analysis, compliance knowledge, and detailed system review. You will work across Medicare, Medicaid, Commercial, and Dual Eligible populations while supporting audit readiness and regulatory adherence.

The role also provides opportunities to identify recurring issues, recommend corrective actions, and improve operational processes. This is a fully remote opportunity available in select U.S. states, with a strong focus on collaboration across operational, technical, and client-facing teams.

Accountabilities:
The Senior Utilization Management Audit & Compliance Analyst will lead audit response activities, investigate UM records, analyze performance data, and support ongoing compliance and process improvement.

• Serve as the primary business lead for external customer audits and utilization management oversight reviews.
• Review audit findings, regulatory inquiries, corrective action requests, and data validation requests from health plans, clients, and regulatory agencies.
• Conduct detailed investigations to validate findings, identify root causes, and determine appropriate responses.
• Gather supporting documentation and evidence from utilization management systems, reporting tools, and operational teams.
• Prepare clear, accurate, professional, and evidence-based written responses to customer audit findings.
• Develop corrective action plans and supporting documentation when required, and monitor their implementation.
• Ensure audit responses are complete, accurate, and delivered within required timelines.
• Participate in customer meetings related to audit findings, performance reviews, and corrective actions.
• Track recurring issues and recommend improvements to processes, controls, and operational practices.
• Review authorization records, cases, determinations, timelines, and workflow activities within Essette and related systems.
• Validate regulatory time frames, determination accuracy, documentation requirements, and case-level information.
• Collaborate with operational teams to resolve discrepancies and provide supporting evidence.
• Analyze utilization management data to support audits, customer inquiries, and business reviews.
• Use advanced Excel capabilities, including Pivot Tables, Pivot Charts, advanced filtering, VLOOKUP/XLOOKUP, conditional formatting, data validation, trend analysis, and large-dataset reconciliation.
• Develop data summaries, reports, and audit exhibits while identifying trends, anomalies, and improvement opportunities.
• Validate the accuracy and completeness of reported UM performance metrics.
• Interpret and apply UM requirements across Medicare, Medicaid, Commercial, and Dual Eligible populations.
• Monitor compliance with CMS, NCQA, state regulatory, and client-specific requirements.
• Identify potential compliance risks and partner with operational leaders on corrective actions and audit readiness.
• Develop audit preparation tools, templates, standard responses, tracking processes, and documentation practices.
• Participate in mock audits and readiness reviews.
• Support the development of policies, procedures, and training materials related to UM compliance and audit activities.

The ideal…