Full Job Description
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
