LogoFresh Jobs Ahead
Alignment Health
Alignment Health
501 – 1,000 Employees
HealthcareHealthcare InsuranceInsurance
Alignment Health is a healthcare insurance company focused on improving care for Medicare members, particularly seniors, people living with chronic conditions, and those who are frail. Founded in 2013, the company combines a personalized care model with technology and a 24/7 concierge care team to coordinate support with trusted local providers. Its work spans healthcare delivery and insurance, with a focus on making care more accessible, responsive, and cost-conscious for its members. Alignment Health hires across a growing healthcare organization serving the needs of Medicare communities.
LinkedIn
Company Jobs

Delegation Oversight Auditor - Utilization and Case Management (LVN/RN) - Remote

Conduct Medicare Utilization Management and Case Management audits for delegated providers at Alignment Health. Evaluate compliance, oversee corrective actions, and support regulatory readiness.

USUnited States
$77,905 – $116,858 / year
RemoteFull-timeMiddleSeniorEnglish RequiredAuditor

Description

  • Conduct Utilization Management and Case Management audits against regulatory, contractual, and industry standards.
  • Assess delegated entities’ compliance with CMS, contractual, and Alignment Health UM/CM requirements.
  • Keep documentation complete, organized, and ready for audit review.
  • Perform audits using approved methodologies, sampling criteria, and risk-based techniques.
  • Communicate audit scope, expectations, schedules, documentation requirements, findings, and corrective actions to delegated provider organizations.
  • Present findings, clarify root causes and performance gaps, and guide delegates on corrective-action requirements.
  • Review and verify Corrective Action Plans and remediation evidence.
  • Monitor CAP progress and complete follow-up activities through resolution.
  • Use historical results, monitoring data, clinical trends, and operational challenges to identify high-risk areas.
  • Recommend audit priorities and adjust audit scopes and schedules as needed.
  • Escalate emerging risks, irregular findings, systemic concerns, and complex CAP matters to the Manager, Audit Administration.
  • Develop audit summaries, reports, dashboards, and materials for leaders, committees, regulators, and executives.
  • Partner with Delegate Performance, Clinical Operations, Quality, Compliance, and other stakeholders.
  • Manage several audits concurrently while supporting training, education, regulatory audit preparation, and special projects.

Requirements

  • Bring 3–5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA environment, including deep knowledge of managed-care clinical operations.
  • Have prior Medicare Managed Care UM/CM experience involving delegated oversight and auditing.
  • Have at least 1–2 years of experience performing oversight audits of delegated entities and/or ancillary providers.
  • Demonstrate detailed knowledge of CMS, HICE, or comparable UM/CM requirements.
  • Hold a required bachelor’s degree in nursing or an equivalent qualification.
  • Possess strong knowledge of Medicare audit practices and state and federal regulations governing UM/CM.
  • Organize and maintain accurate, complete, audit-ready records across multiple concurrent workstreams.
  • Apply strong attention to detail, analytical thinking, and problem-solving skills to assess data, recognize patterns, and identify root causes.
  • Work independently, set priorities, take initiative, and complete assigned work on schedule with limited supervision.
  • Communicate audit findings, expectations, and technical information clearly and professionally in writing and conversation.
  • Protect confidential information and follow HIPAA and all other privacy and data-security standards.
  • Build effective working relationships with colleagues, internal stakeholders, delegated entities, and external partners.
  • Use percentages, proportions, and other calculations, applying basic algebraic and geometric concepts when required for audit work.
  • Demonstrate advanced proficiency in Microsoft Office, particularly Excel, Word, PowerPoint, and Outlook.
  • Understand medical terminology, electronic medical records (EMR), and case management systems.
  • Follow instructions accurately, preserve data integrity, and use sound judgment when evaluating audit evidence.
  • Enter data accurately, including 10-key touch typing.
  • Understand state and federal UM/CM requirements and managed-care operating frameworks.
  • Maintain an active, unrestricted state license as a Licensed Vocational Nurse (LVN) or Registered Nurse (RN).

Related Jobs

Nebius Group

Senior Customer AI Engineer

Nebius Group
1,001 – 5,000 Employees
Artificial IntelligenceEnterpriseSaaS
USUnited States
$209,800 – $262,200 / year
RemoteFull-timeSeniorEnglish RequiredAI EngineerMachine Learning Engineer
CloudDistributed Systems

Guide customers from proof of concept to production on Nebius’s AI cloud platform, helping them deploy AI workloads reliably and at scale. Improve performance, reliability, and cost efficiency while accelerating time to production and customer value.

Open