Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
The Remote Auditor, Delegate UM/CM plays a critical role in supporting Alignment Healthcare’s delegated oversight audit program by conducting Utilization Management (UM) and Case Management (CM) audits to ensure delegated entities meet regulatory, contractual, and operational expectations. Working under the guidance of the Manager, Audit Administration, the Auditor executes risk‑based audits using established methodologies, documentation standards, and evaluative criteria that align with the enterprise audit strategy. In this role, the Auditor evaluates delegated UM and CM operations for compliance with CMS and contractual requirements, as well as Alignment Healthcare’s policies and standards. The Auditor leads audit activities from planning through reporting, synthesizing findings that identify root causes, performance gaps, and opportunities for improvement. Audit documentation is maintained to support regulatory readiness and internal oversight processes. The Auditor also serves as a key liaison to delegated provider organizations, facilitating clear and constructive communication throughout the audit lifecycle. The role supports delegates in understanding findings and required corrective actions, escalating complex or irregular issues to the Manager, Audit Administration for review and resolution. Through effective execution of UM/CM audits, strong cross‑functional collaboration, and adherence to audit‑ready documentation standards, the Auditor supports Alignment Healthcare’s transformation toward a more proactive, data‑driven oversight model and contributes to improved quality, compliance, and performance outcomes across delegated clinical functions.
Job Duties/Responsibilities
Conduct UM/CM audits in accordance with regulatory, contractual, and industry standards:
- Execute Utilization Management (UM) and Case Management (CM) audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
- Evaluate delegated entities’ compliance with CMS and contractual requirements, and Alignment Healthcare’s UM/CM policies and standards.
- Maintain organized, complete, and audit‑ready documentation to support regulatory, accreditation, and internal oversight reviews.
- Ensure all audit activities align with the enterprise audit strategy and risk‑based approach established by the Manager, Audit Administration.
Engage delegated provider organizations to correct deficiencies and improve performance:
- Communicate audit scope, expectations, timelines, required documentation, and process steps clearly to delegated entities throughout the audit lifecycle.
- Present audit findings to delegates, explaining root causes, performance gaps, non‑compliance risks, and potential operational impacts related to UM/CM processes.
- Support delegated entities in understanding UM/CM compliance requirements and expectations for corrective actions.
- Foster professional, collaborative relationships to promote transparent discussions, accountability, and continuous improvement.
Perform risk assessment and prioritize UM/CM audits
- Contribute to identifying high‑risk areas by reviewing historical audit results, monitoring data, clinical performance trends, and operational challenges related to UM/CM.
- Recommend prioritization of UM/CM audits based on severity of risk, regulatory sensitivity, and emerging compliance or clinical performance trends.
- Provide input to refine audit scopes and schedules in alignment with the Manager’s risk‑based UM/CM audit strategy.
- Escalate emerging UM/CM‑related risks, irregular findings, or potential systemic issues to the Manager for strategic review and future audit planning.
Validate corrective actions for UM/CM compliance
- Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses UM/CM deficiencies identified during audits.
- Assess evidence including revised workflows, updated clinical review criteria, policy changes, revised documentation, and utilization management decision processes.
- Track CAP progress and ensure follow‑up activities are completed, documented, and closed in accordance with departmental requirements.
- Escalate irregular, stalled, or complex CAP issues to the Manager, Audit Administration for higher‑level intervention.
Report UM/CM audit findings to facilitate organizational awareness
- Prepare clear, concise, and well‑structured audit summaries that highlight key risks, compliance gaps, operational issues, and improvement opportunities across UM/CM delegated functions.
- Contribute to audit reporting tools, dashboards, and documentation used for internal leadership, cross‑functional teams, and enterprise oversight groups.
- Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal stakeholders to ensure findings are understood, actionable, and integrated into broader performance improvement efforts.
- Support preparation of audit materials and evidence for internal committees, external regulatory bodies, and executive‑level oversight forums.
Additional Responsibilities
- Manage multiple UM/CM audits concurrently, ensuring adherence to established timelines, quality standards, and documentation requirements.
- Monitor UM/CM operational, clinical, and compliance data to identify emerging issues requiring targeted audit review.
- Support the development and delivery of training and education for delegated entities on UM/CM standards, audit expectations, and compliance requirements.
- Assist in preparing documentation and evidence for CMS or other regulatory audits.
- Perform additional responsibilities and special projects as assigned.
Job Requirements
Experience
- 3-5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of clinical operations of managed care operations.
- Prior Medicare Managed Care UM/CM experience related to delegation oversight and auditing.
- 1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers
- Demonstrable detailed knowledge/experience with CMS, HICE, or related UM/CM requirements.
Education
• Required: Bachelor’s Degree in nursing or equivalent
• Preferred: Master’s degree in nursing or related fields (e.g., MHA, MPH, MBA, MSN)
Training
• Required: None
• Preferred: None
Specialized Skills
• Required
- Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing UM/CM.
- Exceptional organizational skills with the ability to maintain accurate, complete, and audit‑ready documentation across multiple concurrent workstreams.
- High attention to detail with strong analytical and problem‑solving capabilities to evaluate data, identify patterns, and determine root causes of issues.
- Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight.
- Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally.
- Ability to maintain confidentiality and comply with HIPAA and all other privacy and data‑security standards.
- Strong interpersonal skills and the ability to build positive, productive working relationships with co‑workers, internal stakeholders, delegated entities, and external partners.
- Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work.
- Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook, and the ability to use these tools to analyze data, document audit findings, and support reporting needs.
- Working knowledge of medical terminology, electronic medical records (EMR), and case management systems.
- Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence.
- Proficient data‑entry skills, including 10‑key by touch, with a high degree of accuracy.
- Solid understanding of state and federal UM/CM requirements and managed‑care operational frameworks.
Licensure
• Required: Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN).
Other
• Required: None
Essential Physical Functions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $77,905.00 - $116,858.00Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.