Remote Auditor, Delegate Utilization/Case Management

R1638 Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. Remote ---The Auditor, Delegate UM/CM plays a critical role in supporting Alignment Healthcare’s delegated oversight audit program by conducting Utilization Management (UM) and Case Management (CM) audits to ensure delegated entities meet regulatory, contractual, and operational expectations. Working under the guidance of the Manager, Audit Administration, the Auditor executes risk‑based audits using established methodologies, documentation standards, and evaluative criteria that align with the enterprise audit strategy. In this role, the Auditor evaluates delegated UM and CM operations for compliance with CMS and contractual requirements, as well as Alignment Healthcare’s policies and standards. The Auditor leads audit activities from planning through reporting, synthesizing findings that identify root causes, performance gaps, and opportunities for improvement. Audit documentation is maintained to support regulatory readiness and internal oversight processes. The Auditor also serves as a key liaison to delegated provider organizations, facilitating clear and constructive communication throughout the audit lifecycle. The role supports delegates in understanding findings and required corrective actions, escalating complex or irregular issues to the Manager, Audit Administration for review and resolution. Through effective execution of UM/CM audits, strong cross‑functional collaboration, and adherence to audit‑ready documentation standards, the Auditor supports Alignment Healthcare’s transformation toward a more proactive, data‑driven oversight model and contributes to improved quality, compliance, and performance outcomes across delegated clinical functions. Job Duties/Responsibilities Conduct UM/CM audits in accordance with regulatory, contractual, and industry standards

• Execute Utilization Management (UM) and Case Management (CM) audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
• Evaluate delegated entities’ compliance with CMS and contractual requirements, and Alignment Healthcare’s UM/CM policies and standards.
• Maintain organized, complete, and audit‑ready documentation to support regulatory, accreditation, and internal oversight reviews.
• Ensure all audit activities align with the enterprise audit strategy and risk‑based approach established by the Manager, Audit Administration. Engage delegated provider organizations to correct deficiencies and improve performance
• Communicate audit scope, expectations, timelines, required documentation, and process steps clearly to delegated entities throughout the audit lifecycle.
• Present audit findings to delegates, explaining root causes, performance gaps, non‑compliance risks, and potential operational impacts related to UM/CM processes.
• Support delegated entities in understanding UM/CM compliance requirements and expectations for corrective actions.
• Foster professional, collaborative relationships to promote transparent discussions, accountability, and continuous improvement. Perform risk assessment and prioritize UM/CM audits
• Contribute to identifying high‑risk areas by reviewing historical audit results, monitoring data, clinical performance trends, and operational challenges related to UM/CM.
• Recommend prioritization of UM/CM audits based on severity of risk, regulatory sensitivity, and emerging compliance or clinical performance trends.
• Provide input to refine audit scopes and schedules in alignment with the Manager’s risk‑based UM/CM audit strategy.
• Escalate emerging UM/CM‑related risks, irregular findings, or potential systemic issues to the Manager for strategic review and future audit planning. Validate corrective actions for UM/CM compliance
• Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses UM/CM deficiencies identified during audits.
• Assess evidence including revised workflows, updated clinical review criteria, policy changes, revised documentation, and utilization management decision processes.
• Track CAP progress and ensure follow‑up activities are completed, documented, and closed in accordance with departmental requirements.
• Escalate irregular, stalled, or complex CAP issues to the Manager, Audit Administration for hig

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