Senior Utilization Management Audit & Compliance Analyst

The Senior Utilization Management Audit & Compliance Analyst serves as the subject matter expert for external customer audits, regulatory inquiries, and utilization management oversight activities. This position is responsible for reviewing audit requests, performing detailed analyses of utilization management data, researching findings within the UM system, Essette, and related systems, and preparing professional, evidence-based responses for health plans, clients, regulators, accreditation organizations, and other external stakeholders.

The ideal candidate possesses extensive Utilization Management experience across Medicare, Medicaid, Commercial, and Dual Eligible populations and maintains a strong understanding of applicable UM regulations, accreditation standards, and delegation requirements. This role requires exceptional analytical, writing, and communication skills, along with advanced Excel proficiency to analyze large data sets, identify trends, validate findings, and support audit responses.

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The Senior Utilization Management Audit & Compliance Analyst’s responsibilities include but are not limited to:

Audit Management & Customer Response

• Serve as the primary business lead for external customer audits and oversight reviews,
• Review audit findings, inquiries, corrective action requests, and data validation requests from health plans, clients, and regulatory agencies.
• Conduct comprehensive investigations to validate audit findings and determine root causes.
• Gather supporting documentation and evidence from UM systems, reporting tools, and operational teams.
• Draft clear, accurate, and professional written responses to customer audit findings.
• Develop corrective action plans and supporting documentation when appropriate.
• Ensure audit responses are completed accurately and within required timelines.
• Assist in customer meetings related to audit findings and performance reviews.
• Track recurring issues and recommend process improvements.
• Support implementation and monitoring of corrective action plans

UM System Review & Investigation

• Conduct detailed reviews of authorization records, cases, determinations, timelines, and workflow activities within Essette.
• Validate regulatory time frames, determination accuracy, and documentation requirements.
• Research audit findings and customer concerns using system data and supporting records.
• Collaborate with operational teams to resolve discrepancies and provide supporting documentation.
• Ensure audit findings are supported by accurate data and complete case reviews.

Data Analysis & Reporting

• Analyze utilization management data to support audits, customer inquiries, and business reviews.
• Utilize advanced Excel functions including: Pivot Tables, Pivot Charts, Advanced Filtering, VLOOKUP/XLOOKUP, Conditional Formatting, Data Validation, Trend Analysis and Reconciliation of large datasets
• Develop data summaries, reports, and audit exhibits.
• Identify trends, anomalies, and opportunities for operational improvement.
• Validate the accuracy and completeness of reported UM performance metrics.

Utilization Management Compliance

• Interpret and apply Utilization Management requirements across Medicare, Medicaid, Commercial, and Dual Eligible populations.
• Monitor compliance with CMS, NCQA , state regulatory, and client-specific requirements.
• Review UM processes for regulatory adherence and operational effectiveness.
• Identify potential compliance risks and recommend corrective actions.
• Partner with operational leaders to improve audit readiness and compliance performance.

Process Improvement & Audit Readiness

• Develop audit preparation tools, templates, and standard responses.
• Establish audit tracking and documentation processes.
• Identify opportunities to improve data accuracy, reporting consistency, and operational compliance.
• Participate in mock audits and readiness reviews.
• Assist in developing policies, procedures, and training materials related to UM compliance and audit activities.

EDUCATION:

• Bachelor’s degree in healthcare administration, public health, or related field preferred

EXPERIENCE:

• 5-10 years of experience in healthcare operations, UM, and/or audit support.
• Strong organizational skills with the ability to manage multiple operational processes and competing deadlines.
• Experience preparing reports and analyzing data.
• Excellent written and verbal communication skills, with attention to detail and accuracy.
• Ability to build strong cross-functional relationships across Operations, IT, and external clients.

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues 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.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.

Powered by JazzHR