UM Operations Clinical Guide

Job Description A bit about this role:
The UM Operations Clinical Guide is a clinical nursing role responsible for supporting the quality, accuracy, compliance, and continuous improvement of Utilization Management (UM) operations within an assigned UM team. This position serves as the team’s clinical audit and monitoring resource, conducting Clinical Review audits, identifying trends and opportunities for improvement, and partnering with UM leadership to ensure processes and clinical decisions align with CMS requirements, regulatory standards, organizational policies, and established clinical criteria.

In addition to audit and monitoring responsibilities, the UM Operations Clinical Guide serves as a key clinical education resource for the assigned team, supporting new-hire on-the-job training (OJT), ongoing staff education, and targeted re-education based on audit findings and identified knowledge gaps. The position works closely with UM Operations, Clinical leadership, Medical Directors, Compliance, Quality, and other cross-functional partners to promote accurate, compliant, and consistent UM practices.

Your Responsibilities and Impact will include:
Conduct ongoing Clinical Review audits and monitoring activities for the assigned UM team, including reviewing clinical determinations, documentation, application of clinical criteria, and adherence to established UM processes. Ensure audit activities are aligned with CMS, regulatory, contractual, and organizational requirements, and maintain audit schedules, sampling requirements, documentation, and monthly audit-cycle deadlines. Analyze audit results to identify trends, root causes, recurring variances, and opportunities for process improvement, and translate findings into actionable recommendations for UM leadership.

Identify opportunities for staff education, re-education, workflow improvement, and process standardization; support new-hire OJT, ongoing staff education, and targeted re-education based on audit findings and identified knowledge gaps. Partner with leaders to develop and implement corrective actions when deficiencies or trends are identified, validate corrective actions, and monitor post-education results to evaluate effectiveness and sustained improvement. Support the development, maintenance, and enhancement of clinical audit tools and methodologies based on changing business needs, regulatory requirements, and identified risk areas.

Support delegation oversight auditing and monitoring activities for applicable UM First Tier, Downstream, and Related Entities (FDRs), including review of delegated UM activities for adherence to applicable clinical, operational, regulatory, and contractual requirements. Support UM readiness activities for internal, external, CMS, and regulatory audits; maintain accurate audit documentation and supporting evidence required to demonstrate compliance. Partner with UM leadership, Medical Directors, UM Operations, Compliance, Quality, Claims, Provider Services, and other stakeholders as appropriate, serving as a clinical subject matter expert for audit findings, clinical documentation, criteria application, and UM processes.

Participate in process improvement initiatives and projects that support quality, compliance, efficiency, and member/provider experience, and escape significant clinical, compliance, or regulatory concerns through established channels.

• Active, unrestricted Registered Nurse (RN) license or Licensed Vocational/ Practical Nurse (LVN/LPN).
• Clinical nursing experience, preferably within Utilization Management, Clinical Review, Quality, Audit, or a related healthcare environment.
• Experience reviewing clinical documentation and applying clinical criteria to healthcare services.
• Know…