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UM Audit & Compliance Nurse (LVN/RN) – MSO/IPA - HYBRID

Location: Pasadena, California
Industry: Healthcare / Managed Care
Employment Type: Part time - Hybrid

Position Overview

We are a growing healthcare Management Services Organization (MSO) seeking an experienced UM Audit & Compliance Nurse (LVN/RN) to oversee our Utilization Management, Case Management, and Quality Improvement operations.

The ideal candidate is a strong healthcare leader with hands-on experience in managed care, utilization management, regulatory compliance, health plan requirements, and clinical operations. This position will be responsible for UM audits/compliance, ensuring timely authorization processing, maintaining regulatory and health plan compliance, and supporting the continued growth of our organization.

• Coordinate and manage health plan delegation oversight, annual audits, focused audits, and compliance reviews related to Utilization Management.
• Serve as the primary point of contact for UM-related health plan audits and audit follow-up.
• Prepare and coordinate responses to L.A. Care, Health Net, Molina, and other contracted health plan audits.
• Review and interpret health plan audit tools, case-file requests, evidence requirements, and submission instructions.
• Identify, collect, and organize required UM case files, authorization records, clinical documentation, policies, procedures, reports, logs, and supporting evidence.
• Review UM authorization files prior to submission to ensure documentation is complete and responsive to applicable health plan, regulatory, contractual, and delegation requirements.
• Prepare and submit audit case files, supporting evidence, and formal responses within required deadlines.
• Communicate directly with health plan nurse auditors, clinical auditors, compliance representatives, and delegation oversight teams.
• Respond to health plan requests for clarification, additional documentation, and follow-up information.
• Participate in case conferences, entrance conferences, audit meetings, exit conferences, and post-audit follow-up activities.
• Coordinate with UM leadership and Medical Directors when clinical clarification or additional case information is required.
• Coordinate required quarterly, annual, supplemental, and ad hoc UM health plan reporting, including HICE and other applicable delegated oversight submissions.
• Maintain and monitor health plan audit calendars, reporting schedules, audit schedules, deliverables, and submission deadlines.
• Track audit findings, deficiencies, requests for additional information, and required follow-up through resolution.
• Prepare and coordinate Corrective Action Plan (CAP) responses and supporting evidence when required.
• Maintain organized audit records and support continuous UM audit and delegation readiness.
• Monitor applicable health plan and regulatory audit requirements, including CMS, DHCS, DMHC, Medi-Cal, Medicare, and NCQA requirements related to delegated Utilization Management.

Qualifications

• Active California LVN or RN license required.
• Direct experience working within an MSO, IPA, PPG, delegated medical group, or similar managed care environment required.
• Strong working knowledge of Utilization Management, prior authorization, and delegated UM processes.
• Hands-on experience with health plan audits, delegation oversight, UM file audits, and/or regulatory compliance reviews required.
• Experience working with L.A. Care, Health Net, Molina, and/or other California health plans strongly preferred.
• Knowledge of CMS, DHCS, DMHC, Medi-Cal, Medicare, NCQA, and health plan contractual requirements as they relate to Utilization Management.
• Experience with HICE reporting, quarterly/annual submissions, audit tools, case-file audits, and Corrective Action Plans (CAPs) preferred.
• Ability to interpret health plan audit requirements and identify the appropriate documentation and evidence needed for submission.
• Strong clinical review, analytical, written communication, organizational, and time-management skills.
• Strong attention to detail with the ability to manage multiple audit requests and deadlines.
• Ability to work independently and take ownership of audit activities from initial request through final resolution.
• Comfortable communicating directly with health plan clinical auditors and participating in audit and case-review conferences.
• CMC, CCM, or CPUR certification or similar healthcare/managed care certification.
• Experience with InterQual or similar utilization review criteria.
• Experience with Medi-Cal managed care and delegated healthcare operations.
• Familiarity with EZ-CAP and/or QuickCap.

What We Offer

• Competitive compensation.
• Benefits package.
• Professional growth and advancement opportunities.
• Collaborative healthcare leadership environment.
• Opportunity to play a key role in improving healthcare delivery, operational efficiency, and regulatory compliance within a growing MSO.