Utilization Management Auditor

Job Summary and Responsibilities

As our Senior Compliance Specialist, you will play a critical role in safeguarding organizational integrity by directing the planning, development, and implementation of a comprehensive monitoring and auditing program for contracted health plan operational functions, including utilization management, quality assurance, and network management. You will serve as a vital link between departmental leadership and regulatory bodies, ensuring that all health plan delegation oversight programs are executed with precision to support CommonSpirit Health’s commitment to departmental compliance and excellence.

Every day you will lead the execution of monitoring and auditing plans to assess the compliance of Utilization, Quality, and Network Management departments with Federal and State regulations, including CMS, DMHC, and DHCS requirements, as well as NCQA accreditation standards. Your work involves conducting rigorous reviews of policies, procedures, and case files, while proactively guiding departments through external audits and managing the execution of necessary corrective action plans to mitigate risk and strengthen internal controls.

To be successful in this role, you will leverage your expertise in managed healthcare and HMO operations to provide strategic leadership and business direction. You will act as a subject matter expert, supporting staff education on evolving legal requirements and recommending data-driven improvements to workflows and tools. By fostering collaborative relationships across the organization and representing CommonSpirit Health in industry regulatory collaboratives, you will drive a culture of continuous improvement and ensure sustained adherence to the highest standards of healthcare compliance.

• Direct the planning, development, and implementation of a robust monitoring and auditing program for health plan operational functions.
• Oversee utilization management, quality, and network management compliance across the organization.
• Execute health plan delegation oversight programs to support CommonSpirit Health’s departmental compliance objectives.
• Develop and implement audit plans to assess compliance with Federal and State laws, regulations, and accreditation standards.
• Guide departments through Health Plan and State audits, ensuring the successful execution of corrective action plans.
• Provide leadership and business direction to Corporate Responsibility and Operations teams regarding regulatory requirements.

#Utilization Management, Managed Care, Health Plan Compliance, NCQA, Auditing, Delegation Oversight, CMS Regulations, Data Analysis

Job Requirements

Required

• Education: Bachelor’s degree (BSN preferred).
• Experience: Minimum five (5) years of experience in managed healthcare/HMO utilization management, program operations compliance, or auditing.
• Utilization Management: Minimum three (3) years of specific experience in Utilization Management Auditing.
• Regulatory Knowledge: Deep understanding of federal and state laws (CMS, DMHC, DHCS) and NCQA accreditation standards.
• Technical Proficiency: Advanced skills in Google Workspace (Docs, Sheets, Slides) and data analysis.
• Soft Skills: Strong interpersonal, conflict resolution, analytical, and planning skills with a proven ability to communicate complex information to diverse audiences.

Where You’ll Work

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.