Senior Utilization Management Audit & Compliance Analyst

Accountabilities:: The Senior Utilization Management Audit & Compliance Analyst will lead audit response activities, investigate UM records, analyze performance data, and support ongoing compliance and process improvement. Serve as the primary business lead for external customer audits and utilization management oversight reviews. Review audit findings, regulatory inquiries, corrective action requests, and data validation requests from health plans, clients, and regulatory agencies. Conduct detailed investigations to validate findings, identify root causes, and determine appropriate responses. Gather supporting documentation and evidence from utilization management systems, reporting tools, and operational teams. Prepare clear, accurate, professional, and evidence-based written responses to customer audit findings. Develop corrective action plans and supporting documentation when required, and monitor their implementation. Ensure audit responses are complete, accurate, and delivered within required timelines. Participate in customer meetings related to audit findings, performance reviews, and corrective actions. Track recurring issues and recommend improvements to processes, controls, and operational practices. Review authorization records, cases, determinations, timelines, and workflow activities within Essette and related systems. Validate regulatory time frames, determination accuracy, documentation requirements, and case-level information. Collaborate with operational teams to resolve discrepancies and provide supporting evidence. Analyze utilization management data to support audits, customer inquiries, and business reviews. Use advanced Excel capabilities, including Pivot Tables, Pivot Charts, advanced filtering, VLOOKUP/XLOOKUP, conditional formatting, data validation, trend analysis, and large-dataset reconciliation. Develop data summaries, reports, and audit exhibits while identifying trends, anomalies, and improvement opportunities. Validate the accuracy and completeness of reported UM performance metrics. Interpret and apply UM requirements across Medicare, Medicaid, Commercial, and Dual Eligible populations. Monitor compliance with CMS, NCQA, state regulatory, and client-specific requirements. Identify potential compliance risks and partner with operational leaders on corrective actions and audit readiness. Develop audit preparation tools, templates, standard responses, tracking processes, and documentation practices. Participate in mock audits and readiness reviews. Support the development of policies, procedures, and training materials related to UM compliance and audit activities. Requirements: The ideal candidate combines substantial utilization management experience with strong analytical, regulatory, writing, and cross-functional collaboration skills. 5–10 years of experience in healthcare operations, utilization management, and/or audit support. Extensive experience with Utilization Management across Medicare, Medicaid, Commercial, and Dual Eligible populations. Strong understanding of applicable UM regulations, accreditation standards, and delegation requirements. Experience reviewing audit findings, investigating root causes, validating data, and preparing formal responses. Strong data analysis and reporting experience, including the ability to work with large and complex datasets. Advanced Excel proficiency, including Pivot Tables, Pivot Charts, VLOOKUP/XLOOKUP, advanced filtering, conditional formatting, data validation, trend analysis, and reconciliation. Experience working with UM systems and related operational or reporting tools; experience with Essette is relevant to the role. Knowledge of CMS, NCQA, state regulatory, and client-specific UM requirements. Excellent written and verbal communication skills, with a strong focus on accuracy and attention to detail. Strong organizational skills and the ability to manage multiple processes, audit requests, and competing deadlines. Ability to build effective cross-functional relationships across Operations, IT, external clients, and other stakeholders. Strong investigative and problem-solving capabilities, with the ability to identify discrepancies and determine appropriate corrective actions. Bachelor’s degree in Healthcare Administration, Public Health, or a related field preferred. Ability to work effectively in a remote environment and collaborate with geographically distributed teams. Benefits: Annual salary of $90,000 . Competitive compensation and annual bonus program. 401(k) retirement program with company match. Company-paid life insurance. Company-paid short-term disability coverage, subject to location restrictions. Medical, vision, and dental benefits. Paid Time Off (PTO). Paid parental leave and sick time. Paid company holidays and floating holidays. Quarterly company-sponsored events. Health and wellness programs. Career development opportunities. Remote work opportunity available in Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington . Opportunity to contribute to healthcare audit readiness, regulatory compliance, utilization management quality, and operational improvement.