Clinical Audit Specialist - Utilization Management

CareSource • Dayton, OH

1d • Onsite

About The Position

The Clinical Audit Specialist - Utilization Management is responsible for conducting retrospective and focused audits of medical necessity determinations to ensure accuracy, regulatory compliance, and alignment with evidence-based clinical criteria. This role serves as a subject matter expert in medical necessity criteria to evaluate utilization management decisions across physical and/or behavioral health services and provide recommendations to improve consistency while ensuring adherence to state, federal, accreditation, and organizational requirements.

Requirements

• Associates of Science (A.S) in Nursing (ASN) required
• 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
• Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
• Advanced knowledge of medical necessity review process
• Strong proficiency in application and interpretation of evidence-based criteria
• Understanding of Medicaid, Medicare, and/or Commercial regulatory requirements
• Ability to analyze complex clinical documentation and identify risk exposure
• Proficient in navigational and data entry skills, Microsoft Outlook, Word, Excel
• Strong communication and collaboration skills- oral and written, professional and respectful
• Ability to exercise independent and sound judgment in decision making with a high level of critical thinking
• Detailed-oriented with strong analytical skills
• Excellent organizational and time management skills
• Ability to manage multiple priorities concurrently
• Excellent follow-through skills and attention to detail
• Culturally competent, member centric, and customer focused
• Proper grammar usage and phone etiquette
• Exhibits change resiliency

Nice To Haves

• Bachelor of Science (B.S) in Nursing (BSN) preferred
• Experience conducting retrospective reviews, quality audits, or compliance reviews preferred
• Experience with analysis, data and reporting preferred
• Multi state licensure required within 6 months of hire, if offered in home state
• MCG Certification(s) is required or must be obtained within six (6) months of hire

Responsibilities

• 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.
• Provide support for internal and external audit readiness by collaborating with UM Operations to ensure compliance with state, federal, CMS and accreditation standards.
• Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.
• Maintain current knowledge of regulatory requirements, clinical guidelines, and organizational policies impacting utilization management and audit practices.
• Conduct independent research and analysis to identify opportunities for improvement and recommend evidence-based solutions.
• Work collaboratively with internal stakeholders to support organizational goals and quality improvement initiatives.
• Perform any other job related duties as requested.

Benefits

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 11-50 employees