Delegation Oversight Auditor, Case Management (LVN/RN Required)

Alignment Health

. Conduct Utilization Management and Case Management audits in accordance with regulatory, contractual, and industry standards .

Posted 9/21/2026full-timeRemote • United StatesMid-LevelSenior💰 $77,905 - $116,858 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Case Management auditing, with a strong focus on compliance with CMS and regulatory standards. Proficient in managing multiple audits, maintaining audit-ready documentation, and effectively communicating findings to stakeholders.

Highest-signal resume keywords

Utilization Management ExperienceCase Management AuditingCMS Compliance KnowledgeBachelor’s Degree in NursingActive State License for LVN or RN

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Audit MethodologiesData AnalysisCorrective Action PlansMathematical SkillsDocumentation Management

Soft Skills

Organizational SkillsAttention to DetailProblem-Solving SkillsCommunication SkillsInterpersonal Skills

Tools & Technologies

Microsoft ExcelMicrosoft WordMicrosoft PowerPointMicrosoft OutlookElectronic Medical Records (EMR)

Certifications & Qualifications

Licensed Vocational Nurse (LVN)Registered Nurse (RN)

Industry Keywords

Medicare AdvantageHMODelegation OversightManaged Care OperationsHIPAA Compliance

About the role

Key responsibilities & impact

Conduct Utilization Management and Case Management audits in accordance with regulatory, contractual, and industry standards
Evaluate delegated entities’ compliance with CMS, contractual, and Alignment Healthcare UM/CM requirements
Maintain complete, organized, and audit-ready documentation
Execute audits using established methodologies, sampling criteria, and risk-based approaches
Communicate audit scope, expectations, timelines, documentation needs, findings, and corrective actions to delegated provider organizations
Present findings, explain root causes and performance gaps, and support delegates with corrective-action requirements
Review and validate Corrective Action Plans and evidence of remediation
Track CAP progress and complete follow-up activities through closure
Identify high-risk areas using historical results, monitoring data, clinical trends, and operational challenges
Recommend audit prioritization and refine audit scopes and schedules
Escalate emerging risks, irregular findings, systemic issues, and complex CAP matters to the Manager, Audit Administration
Prepare audit summaries, reports, dashboards, and materials for leadership, committees, regulators, and executives
Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other stakeholders
Manage multiple concurrent audits and support training, education, regulatory audit preparation, and special projects

Requirements

What you’ll need

3-5 years of Utilization and Case Management experience in an HMO, Medicare Advantage, and/or IPA setting, with in-depth knowledge of clinical operations of managed care operations
Prior Medicare Managed Care UM/CM experience related to delegation oversight and auditing
1-2 years minimum experience conducting oversight audits of delegated entities and/or ancillary providers
Demonstrable detailed knowledge/experience with CMS, HICE, or related UM/CM requirements
Required: Bachelor’s Degree in nursing or equivalent
Strong knowledge of Medicare audit processes and applicable state and federal regulatory requirements governing UM/CM
Exceptional organizational skills with the ability to maintain accurate, complete, and audit-ready documentation across multiple concurrent workstreams
High attention to detail with strong analytical and problem-solving capabilities to evaluate data, identify patterns, and determine root causes of issues
Demonstrated ability to take initiative, manage priorities, and drive assigned tasks to timely completion with minimal oversight
Excellent verbal and written communication skills, with the ability to convey audit findings, expectations, and technical information clearly and professionally
Ability to maintain confidentiality and comply with HIPAA and all other privacy and data-security standards
Strong interpersonal skills and the ability to build positive, productive working relationships with co-workers, internal stakeholders, delegated entities, and external partners
Strong mathematical skills, including the ability to calculate percentages, proportions, and other figures, and apply basic algebraic and geometric concepts as needed in audit work
Advanced proficiency with Microsoft Office applications, especially Excel, Word, PowerPoint, and Outlook
Working knowledge of medical terminology, electronic medical records (EMR), and case management systems
Ability to follow instructions accurately, maintain data integrity, and apply sound judgment in evaluating audit evidence
Proficient data-entry skills, including 10-key by touch, with a high degree of accuracy
Solid understanding of state and federal UM/CM requirements and managed-care operational frameworks
Required: Active, unrestricted State License for Licensed Vocational Nurse (LVN) or Registered Nurse (RN)