Delegation Oversight Clinical Auditor

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

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

As a condition of employment , the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.
Current/former UC employees are subject to a personnel file review.