Clinical Audit Specialist - Utilization Management

CareSource Management Group Company

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• Conduct retrospective and targeted audits of utilization management medical necessity determinations, including pre-service, concurrent, and post-service reviews to ensure accuracy and compliance.
• Evaluate the application of evidence-based clinical criteria (MCG, InterQual) and adherence to organizational medical and administrative policies in utilization management decisions.
• Assess clinical documentation and the rationale behind medical necessity determinations for compliance with state, federal, CMS, and accreditation standards.
• Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making processes across physical and behavioral health services.
• Prepare comprehensive audit reports detailing findings, identified risks, and actionable recommendations for corrective action and process improvement to leadership.
• Collaborate with Medical Directors, Utilization Management leadership, and operational teams to address complex audit findings and resolve compliance concerns.
• Support internal and external audit readiness by partnering with UM Operations to ensure alignment with regulatory and contractual requirements.
• Participate in policy review and process improvement initiatives aimed at strengthening the accuracy, consistency, and defensibility of medical necessity determinations.
• Maintain current knowledge of evolving regulatory requirements, clinical guidelines, and organizational policies impacting utilization management and audit practices.
• Conduct independent research and analysis to identify opportunities for improving audit quality and clinical decision-making outcomes.
• Work collaboratively with cross-functional stakeholders to support organizational quality improvement initiatives and ensure member-centric care standards.
• Apply advanced knowledge of medical necessity review processes and interpret clinical documentation to identify potential risk exposure and compliance gaps.
• Demonstrate strong proficiency in navigating and using Microsoft Outlook, Word, and Excel for data entry, reporting, and communication tasks.
• Exhibit detailed-oriented work habits with exceptional analytical, organizational, and time management skills to manage multiple priorities concurrently.
• Exercise independent and sound judgment with high-level critical thinking in evaluating complex clinical and administrative cases.
• Communicate clearly and professionally through oral and written channels, maintaining proper grammar, phone etiquette, and respectful interactions.
• Demonstrate cultural competence, member-focused behavior, and resilience to change while supporting organizational goals.
• Perform additional job-related duties as assigned to support operational needs and quality objectives.

🎯 Requirements

• Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice
• Associates of Science (A.S) in Nursing (ASN) required; Bachelor of Science (B.S) in Nursing (BSN) preferred
• Five (5) years of clinical or related healthcare industry experience
• Two (2) years of Utilization Management/Utilization Review experience with Commercial, Medicaid, or Medicare populations
• Demonstrated experience applying MCG and InterQual evidence-based clinical criteria
• MCG Certification required or must be obtained within six (6) months of hire

🏖️ Benefits

• Compensation range of $62,700.00 - $100,400.00
• Eligibility for a bonus tied to company and individual performance
• Comprehensive total rewards package including well-being benefits
• Remote work environment
• Multi-state licensure support within six months of hire
• Opportunities for professional development and process improvement involvement

Skills & Technologies

Remote

Degree Required

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CareSource Management Group Company

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About CareSource Management Group Company

CareSource is a nonprofit, multi-state managed care organization headquartered in Dayton, Ohio. Founded in 1989, it administers Medicaid, Medicare Advantage, and Marketplace health plans serving over two million members in Ohio, Kentucky, Indiana, West Virginia, and Georgia. The company focuses on improving health outcomes for low-income and vulnerable populations through integrated care management, behavioral health services, and social determinants programs.

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