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CareSource

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Clinical Audit Specialist – Utilization Management

IT SupportIT SupportFull TimeRemoteSeniorTeam 1,001-5,000Since 30+ yearsH1B SponsorCompany SiteLinkedIn

Location

United States

Posted

51 days ago

Salary

$62.7K - $100.4K / year

Seniority

Senior

Associate Degree5 yrs expEnglish

Job Description

Clinical Audit Specialist – Utilization Management

CareSource

• Conduct retrospective and targeted audits of utilization management medical necessity determinations including pre-service, concurrent, and post service reviews. • Evaluate application of evidence-based clinical criteria (MCG, InterQual) and adherence to medical and administrative policies in utilization management determinations. • Assess clinical documentation, rationale for determinations, and compliance with regulatory and contractual and accreditation requirements. • Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making and utilization management processes. • Prepare comprehensive audit reports summarizing findings, identified risks, and recommendations for corrective action and process improvement to leadership. • Collaborate with Medical Directors, UM leadership and UM Operational teams to address complex audit findings. • Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.

Job Requirements

  • Associates of Science (A.S) in Nursing (ASN) required
  • Bachelor of Science (B.S) in Nursing (BSN) preferred
  • Five (5) years of clinical or related healthcare industry experience required
  • Two (2) years Utilization Management/Utilization Review for Commercial, Medicaid, Medicare populations required
  • Demonstrated experience applying evidence-based criteria, including MCG and InterQual required
  • Managed Care experience required
  • Experience conducting retrospective reviews, quality audits, or compliance reviews preferred
  • Experience with analysis, data and reporting preferred

Benefits

  • health insurance
  • retirement plans
  • paid time off
  • professional development
  • substantial and comprehensive total rewards package
  • bonus tied to company and individual performance

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