Utilization Management Auditor

3 days ago

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HealthAxis Group

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HealthAxis Group is a technology solutions provider specializing in healthcare administration. Their cloud-native platform, AxisCore™, streamlines health plan management through solutions like claims processing and benefit administration, designed to enhance operational efficiency. HealthAxis offers a suite of services including Business Process as a Service (BPaaS), consulting, and staff augmentation. The company's approach focuses on scalability, compliance, and tailored support, aiming to empower healthcare organizations to meet member needs effectively.

Claims Processing Software • Business Process Outsourcing (BPO) • Third Party Administrative Services • business process as a service (BPaaS) • Core Administrative Processing

201 - 500 employees

Founded 1965

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

📋 Description

• HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. • The Utilization Management Auditor plays a critical role in ensuring the accuracy, compliance, and effectiveness of the Utilization Management (UM) processes within the health plan. • This position is responsible for auditing the results of the full UM lifecycle, including intake, authorization creation, and authorization review and determination. • The auditor evaluates processes impacting other departments to ensure that operations align with industry standards, regulatory requirements, and organizational policies. • By identifying inefficiencies, gaps in compliance, and opportunities for improvement, the Utilization Management Auditor supports the organization's commitment to providing high-quality and cost-effective care while ensuring operational excellence.

🎯 Requirements

• High school diploma or general education degree (GED) required. • Bachelor’s degree in Healthcare Administration, Nursing, Business Administration, or related field (preferred). • Certification in Healthcare Compliance (CHC), Certified Professional in Utilization Review (CPUR), or similar certifications are highly desirable. • Additional certifications or training in auditing or healthcare quality improvement is a plus. • Minimum of 3-5 years of experience in healthcare operations, Utilization Management, or auditing roles within health plans or managed care organizations. • In-depth knowledge of UM processes, including intake, authorization creation, and determination, as well as familiarity with cross-departmental functions like claims, A&G, and call center operations. • Experience with healthcare regulations and standards (e.g., CMS, state-specific guidelines, NCQA) and their impact on utilization management. • Proven track record in auditing and identifying areas for process improvement within a complex healthcare environment. • Experience in developing and implementing reporting systems and documentation related to audit activities. • Strong analytical and critical thinking skills, with the ability to identify patterns, discrepancies, and opportunities for improvement. • Excellent attention to detail and the ability to maintain high levels of accuracy in all work products. • Strong communication skills, both verbal and written, to present audit findings clearly and persuasively to stakeholders at all levels. • Ability to work collaboratively across departments, with a customer service-oriented approach to problem-solving. • Proficiency in using audit management tools, electronic health records (EHR) systems, and MS Office Suite (Excel, Word, PowerPoint). • Knowledge of healthcare claims processing and call center operations is a plus. • Ability to manage multiple priorities and meet deadlines in a fast-paced environment.