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Utilization Management Auditor Jobs (NOW HIRING)

Molina Healthcare

Auditor, Clinical Services

Miami, FL

$29.05 - $56.64/hr

Essential Job Duties Performs audits in utilization management, care management, member assessment ... Ensures auditing approaches follow a Molina standard in approach and tool use. Maintains member ...

Molina Healthcare

Auditor, Clinical Services

Orlando, FL

$29.05 - $56.64/hr

Essential Job Duties Performs audits in utilization management, care management, member assessment ... Ensures auditing approaches follow a Molina standard in approach and tool use. Maintains member ...

Molina Healthcare

Auditor, Clinical Services

Tampa, FL

$29.05 - $56.64/hr

Essential Job Duties Performs audits in utilization management, care management, member assessment ... Ensures auditing approaches follow a Molina standard in approach and tool use. Maintains member ...

Molina Healthcare

Auditor, Clinical Services

Miami, FL

$29.05 - $56.64/hr

Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...

Molina Healthcare

Auditor, Clinical Services

Tampa, FL

$29.05 - $56.64/hr

Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...

Molina Healthcare

Auditor, Clinical Services

Miami, FL

$29.05 - $56.64/hr

Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...

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Utilization Management Auditor information

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$15

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$53

How much do utilization management auditor jobs pay per hour?

As of Aug 24, 2026, the average hourly pay for utilization management auditor in the United States is $31.94, according to ZipRecruiter salary data. Most workers in this role earn between $22.36 and $40.62 per hour, depending on experience, location, and employer.

What is a utilization management auditor?

A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.

What are the key skills and qualifications needed to thrive as a utilization management auditor?

To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.

What are some common challenges faced by utilization management auditors and how can they be addressed?

Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.

What is the difference between Utilization Management Auditor vs Utilization Review Nurse?

AspectUtilization Management AuditorUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or CUCLicensed Registered Nurse (RN), often with additional certifications
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinics, insurance companies, often in clinical settings
Primary FocusAuditing and reviewing utilization data for compliance and cost managementAssessing patient care needs and determining appropriate services

While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.

More about Utilization Management Auditor jobs

What cities are hiring for Utilization Management Auditor jobs?

Cities with the most Utilization Management Auditor job openings:

What states have the most Utilization Management Auditor jobs?

States with the most job openings for Utilization Management Auditor jobs include:

What job categories do people searching Utilization Management Auditor jobs look for?

The top searched job categories for Utilization Management Auditor jobs are:

Utilization Management Auditor jobs near you
Infographic showing various Utilization Management Auditor job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 13% Part Time, and 2% Contract. Highlights an 84% Physical, 3% Hybrid, and 13% Remote job distribution, with an average salary of $66,436 per year, or $31.9 per hour.

Director of Utilization Management

Blue Cross and Blue Shield of Minnesota

Eagan, MN • On-site

$237K - $248K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 16 days ago

Blue Cross Blue Shield Of Minnesota rating

7.1

Company rating: 7.1 out of 10

Based on 9 frontline employees who took The Breakroom Quiz

251st of 311 rated insurance

Job description

About Blue Cross and Blue Shield of Minnesota
At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.
The Impact You Will Have
The Director of Utilization Management leads and directs the utilization review staff is responsible for ensuring policies and procedures incorporate best practices and ensure efficient and effective utilization reviews. They manage and monitor prior authorizations and concurrent reviews through the clinical appeals process to ensure that the member is getting the right care in a timely and cost-effective way. They also manage retrospective reviews after treatment has been completed, which includes oversight of the clinical payment integrity team. They partner with the UM Product Manager to identify significant utilization trends, patterns, and provider behavior. The incumbent adapts operations as needed to drive value in line with the product roadmap. They consult and collaborate with internal and external teams to gain alignment and improved utilization of effective and appropriate services. The director ensures that business objectives are aligned to the product strategy, holds associates accountable to efficiency and productivity standards that ensure financial, compliance and quality objectives are met.
Your Responsibilities
  • Provide strategic direction, leadership, and operations oversight to programs and staff to optimize efficiency and effectiveness of Utilization Management operations, deliver positive health outcomes, meet/exceed performance guarantees and increase stakeholder satisfaction.
  • Collaborate with strategic partners and external customers to innovate, design and deliver operational rigor that supports the utilization management product strategy and delivers value to customers in alignment with corporate and divisional priorities.
  • Direct operational readiness and regulatory/accreditation compliance via formal processes such as policy and procedure, program descriptions, auditing, training, and metric monitoring and management.
  • Lead the evaluation of operational performance based on performance against industry benchmarks and acts on opportunities to enhance and improve.
  • Direct the creation, prioritization, and execution of approved business cases. Lead the creation and communication of program performance value through formal and informal presentations, dashboards, RFP content, client meetings and committee participation.
  • Serves as a change leader supporting, communicating and taking personal ownership of operational strategy and success criteria.
  • Leverage vendor partners and build a network among external market influencers, including regulatory bodies and Blue Plan resources, to bring new ideas and solutions that increase the value delivered to all stakeholders and to communicate existing value to the market.
  • Constantly scans the market for tools and technology that will improve operational efficiency and quality. Champions adoption and implementation of those tools that will drive business value.
  • Partners with workforce management to drive toward standardized metrics to measure productivity and quality. Establishes process to continually monitor teams' progress against established standards and holds staff accountable to meeting standards.
  • Create and foster an environment where Medical Management staff can work effectively and efficiently at the top of their licensure.
  • Leads and directs a high performing team including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.
  • With the UM Product Manager, is accountable for the delivery of utilization management Affordability of Care (AOC) targets

Required Skills and Experience
  • Accepting this position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.
  • 7+ years of related professional experience, with 3+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
  • Demonstrated maturity, flexibility and capacity to navigate a complex structure with strong critical thinking, problem solving/conflict resolution skills.
  • Superior facilitation, written and oral communications skills to convey complex ideas simply, through written reports and presentation materials.
  • Strong leadership skills with the ability to generate ideas, support and commitment from constituents.
  • Demonstrated team building, mentoring and coaching skills with experience leading professional staff.
  • Strong business acumen and understanding of cross-industry business practices, market and competitive drivers.
  • Demonstrated ability to drive and execute results in a complex cross functional environment.
  • Demonstrated knowledge of healthcare payer industry and business processes.
  • Ability to see across the enterprise and identify potential risks and issues that impact other ongoing work efforts.
  • Strong teamwork and interpersonal skills at all levels.
  • Must be able to work effectively with cross functional groups, fostering teamwork with a commitment to quality.
  • Demonstrated ability to understand business strategy, including deep expertise with the accountability of scope and relate that strategy to program execution business knowledge across multiple functional areas.
  • Strategic thinking and critical decision making at an enterprise level.
  • Ability to thrive in ambiguity and adapt approach as needed.
  • High school diploma (or equivalency) and legal authorization to work in the U.S.

Preferred Skills and Experience
  • Advanced degree in business, finance or healthcare administration
  • Health plan program leadership experience
  • Current MN state licensure without restriction (i.e., RN or licensed independent mental health practitioner preferred)

Role Designation
Hybrid
Anchored in Connection
Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week - most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.
Compensation and Benefits
$135,500.00 - $182,900.00 - $230,300.00 Annual
Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.
We offer a comprehensive benefits package which may include:
  • Medical, dental, and vision insurance
  • Life insurance
  • 401k
  • Paid Time Off (PTO)
  • Volunteer Paid Time Off (VPTO)
  • And more

To discover more about what we have to offer, please review our benefits page.
Equal Employment Opportunity Statement
At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic.
Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

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