Job Description: This position documents and audits SelectHealth Health Services caregivers and delegated entities on the execution of care and utilization management processes, policies, procedures, and guidelines to confirm they are completed in an effective and consistent manner; aligned with regulatory guidelines (Centers for Medicare and Medicaid Services [CMS], federal and state [Accountable Care Organizations {ACO}, Medicaid programs]); applicable accrediting organization standards (i.e., National Committee for Quality Assurance [NCQA]); recognized industry standards of practice; coverage benefits; and written service agreements to ensure the responsible provision of administrative and/or health care services to SelectHealth covered individuals and use of company financial resources.This position documents and audits SelectHealth Health Services caregivers and delegated entities on the execution of care and utilization management processes, policies, procedures, and guidelines to confirm they are completed in an effective and consistent manner; aligned with regulatory guidelines (Centers for Medicare and Medicaid Services [CMS], federal and state [Accountable Care Organizations {ACO}, Medicaid programs]); applicable accrediting organization standards (i.e., National Committee for Quality Assurance [NCQA]); recognized industry standards of practice; coverage benefits; and written service agreements to ensure the responsible provision of administrative and/or health care services to SelectHealth covered individuals and use of company financial resources. Scope SelectHealth Inc. and external delegates for Care and Utilization Management Job Essentials Utilizes audit tools, activity reports, and expert knowledge of the prevailing standards of practice, processes, policies, procedures, and regulatory guidelines related to Care and Utilization Management to audit and oversee performance of Health Services employees and delegated entities. This includes case file documentation, recorded phone conversations, application of medical criteria, adherence to policies, procedures, approved work processes, regulatory guidelines and expectations, and other aspects of other aspects of medical management. Provides reports via professionally written deliverables to Health Services management, Compliance Consultants, oversight committee(s), and delegated entities regarding findings from auditing and monitoring activities. Conducts and/or participates in focused audits as necessary including pre-delegation audits, program and regulatory audits, data and corrective action validation audits, and quality assurance reviews. Participates in risk assessments to provide reasonable assurance that risk management strategies and controls are functioning appropriately. Evaluates information identified in audits and via oversight monitoring; and provides recommendations to the Educator and/or Health Services management team on areas for improvement at the individual caregiver and department level. Collaborates with Health Services management, Health Services Trainer/Nurse Educator, Compliance Consultants, and delegated entities to identify the need for changes to policies, procedures, and other work processes. Coordinates with Health Services management and the Trainer/Nurse Educator to provide follow-up to Health Services caregivers on audit findings. Works with Health Services management, Health Services Trainer/Nurse Educator, and/or delegated entities to develop and maintain an audit tool and/or oversight monitoring processes that measure the efficacy and adherence of Health Services caregivers to prevailing policies, procedures and work processes, and measure the efficacy and adherence of delegated entities to their contractual obligations and service level agreements for the provision of Care and Utilization Management services. Maintains an awareness of CMS, State Medicaid, and NCQA requirements related to health plan Care and Utilization Management, and Population Health services. Establishes and maintains effective communications/professional relationships with delegated and prospectively delegated entities. Minimum Qualifications Clinical Social Worker with a license to practice in the State of Utah or Registered Nurse with a current license to practice in the State of Utah. Certified Case Manager (CCM) designation must be achieved within 12 months of hire/transition into this position. Bachelor's degree in nursing (BSN) from an accredited institution (degree will be verified). or Master's degree in Social Work (MSW). Degree must be obtained from an accredited institution. Education is verified. Two years of broad clinical care management or health insurance experience. Two years of audit-related experience in health care or data analysis. Experience requiring effective problem-solving, critical thinking, process analysis, and other strong analytical skills. Demonstrated and consistent pattern of professional written and verbal communication skills. A working understanding of CPT 4 and ICD-10-CM coding. Demonstrated proficiency using word processing, spreadsheets, and calendaring. Demonstrated ability to work independently and be self-motivated with a positive attitude and flexibility in a rapidly changing environment. Preferred Qualifications Experience with health insurance, government programs (i.e., Medicare, Medicaid), or work in a highly regulated environment. Knowledge of SelectHealth products. Physical Requirements: SH only Interact with others requiring the employee to communicate information. - and - Operate computers and other office equipment requiring the ability to move fingers and hands. - and - See and read computer monitors and documents. - and - Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment. Location: SelectHealth - Murray Work City: Murray Work State: Utah Scheduled Weekly Hours: 40 The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $43.98 - $63.79 We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers , and for our Colorado, Montana, and Kansas based caregivers ; and our commitment to diversity, equity, and inclusion . Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. All positions subject to close without notice.