Utilization Management Auditor

Dignity Health • Rancho Cordova, CA

7d • $39 - $58

About The Position

The position directs the planning, development, and implementation of monitoring and auditing programs for contracted health plan operational functions, including utilization management, quality assurance, and network management. It supports organizational compliance by overseeing health plan delegation oversight programs and assessing adherence to federal and state requirements, including CMS, DMHC, and DHCS regulations, as well as NCQA accreditation standards.

The role leads monitoring and audit plans, reviews policies, procedures, and case files, guides departments through health plan and state audits, and manages corrective action plans to mitigate risk and strengthen internal controls. It provides leadership and business direction to Corporate Responsibility and Operations teams, serves as a subject matter expert on regulatory requirements, supports staff education, and recommends data-driven improvements to workflows and tools. The role also fosters cross-organizational collaboration and represents CommonSpirit Health in industry regulatory collaboratives.

Requirements

• Bachelor’s degree; BSN preferred.
• At least five years of experience in managed healthcare/HMO utilization management, program operations compliance, or auditing.
• At least three years of specific experience in Utilization Management Auditing.
• Deep understanding of federal and state laws and regulations, including CMS, DMHC, and DHCS requirements, and NCQA accreditation standards.
• Advanced skills in Google Workspace, including Docs, Sheets, and Slides, and data analysis.
• Strong interpersonal, conflict resolution, analytical, and planning skills.
• Proven ability to communicate complex information to diverse audiences.

Nice To Haves

• Bachelor of Science in Nursing (BSN).

Responsibilities

• Direct the planning, development, and implementation of a monitoring and auditing program for health plan operational functions.
• Oversee compliance for utilization management, quality, and network management across the organization.
• Execute health plan delegation oversight programs in support of departmental compliance objectives.
• Develop and implement audit plans to assess compliance with federal and state laws, regulations, and accreditation standards.
• Review policies, procedures, and case files as part of monitoring and audit activities.
• Guide departments through health plan and state audits and ensure corrective action plans are executed.
• Provide leadership and business direction to Corporate Responsibility and Operations teams regarding regulatory requirements.
• Support staff education on evolving legal requirements and recommend data-driven improvements to workflows and tools.
• Foster collaborative relationships and represent CommonSpirit Health in industry regulatory collaboratives.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior