Utilization Management Auditor

The Utilization Management Auditor role involves 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. The position serves as a vital link between departmental leadership and regulatory bodies, ensuring compliance with federal and state regulations, as well as NCQA accreditation standards. The role requires conducting rigorous reviews of policies, procedures, and case files, while proactively guiding departments through external audits and managing corrective action plans to mitigate risk and strengthen internal controls.