Description
UCLA HEALTH
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Description
As a Clinical Auditor for the UCLA Health
Medicare Advantage Plan, you will independently assess whether delegated
clinical decisions and services are appropriate for members and supported by
the clinical record.
Reporting to the Associate Director of
Delegated Oversight & Systems, you will serve as the clinical subject
matter expert for the review of services performed by contracted Independent
Physician Associations (IPAs) and other delegated entities. Your work will span
utilization management, case management, population health management, disease
management, behavioral health, transitions of care, and related quality
activities.
In this role,
you will:
- Conduct the clinical components of
pre-delegation, annual, and focused audits. - Review member assessments, risk
stratification, care plans, interventions, referrals, and transitions of care
to determine whether they are clinically appropriate and supported by the
source record. - Evaluate clinical decisions, service
authorizations, and medical necessity determinations using the underlying
clinical documentation. - Validate the effectiveness of corrective
actions and support audit readiness. - Communicate clinical audit findings, identify
trends, and escalate clinical risks.
You will exercise independent clinical
judgment to complement administrative and process oversight and support the
Plan’s retained authority, responsibility, and accountability for delegated
services. Your work will align with the Delegation Criteria and Activities
Agreement and applicable CMS, DMHC, NCQA, and Medicare Advantage requirements.
Salary Range: $88,900 – $190,300/annually
Qualifications
We’re seeking a detail-oriented nurse with:
Required:
- A Bachelor’s degree in Nursing
- An Active unrestricted California Registered
Nurse (RN) license - 5 or more years of experience in nursing,
including managed care, health, plan, utilization management, behavioral
health, or related operations - 3 or more years of experience performing
utilization management, care management, population health, clinical quality
review, clinical audit, or delegated clinical oversight - 3 or more years of experience conducting
clinical record review, medical necessity review, denial review, audit testing,
or validation of clinical decisions and documentation - Knowledge of Medicare Advantage delegation
oversight requirements, plan accountability for delegated services, and
applicable CMS, DMHC, NCQA, and OIG compliance guidance - Clinical knowledge of Utilization Management,
Case Management, Population Health Management, Disease Management, Behavioral
Health, and Transitions of Care - Ability to distinguish administrative or process
completion from clinical appropriateness and independently perform the clinical
component of oversight reviews - Ability to evaluate assessments, risk
stratification, care plans, interventions, referrals, follow-up, transitions,
and escalation against identified member needs and source evidence - Knowledge of medical necessity review principles
and ability to evaluate clinical rationale, documentation, criteria
application, and timeliness in authorization and denial files - Ability to plan and conduct pre-delegation,
annual, and focused clinical audits using source records, policies, committee
evidence, and delegated entity submissions - Ability to identify clinical, compliance, and
documentation deficiencies; synthesize findings; and recommend clear corrective
actions and risk escalation - Ability to validate corrective action
effectiveness through follow-up testing, evidence review, performance
monitoring and trend analysis - Strong written communication skills for clinical
audit reports, findings, corrective actions, scorecards, committee materials,
and executive summaries - Strong verbal communication and stakeholder
management skills with delegated entities and internal clinical, compliance,
quality, and operational partners - Ability to exercise independent professional
clinical judgement while maintaining objectivity, consistency, confidentiality,
and audit-defensible documentation - Ability organize regulatory and accreditation
evidence and support CMS and accreditation audit readiness activities - Proficiency with Microsoft Office applications
and enterprise collaboration or documentation repositories used to perform and
document oversight work
Preferred:
- A Master’s degree in Nursing, Public Health,
Healthcare Administration, or a related field - Certified Professional in Healthcare Quality
(CPHQ) or Certified Case Manager (CCM) - Training in CMS, NCQA, healthcare compliance,
utilization management or clinical audit - 3 or more years of experience supporting
Medicare Advantage, CMS, DMHC, NCQA, accreditation, compliance, or delegation
oversight reviews. - 3 or more years of experience developing
clinical findings, corrective actions, follow-up testing, trend analysis, or
remediation validation