<h3><b>Become a part of our caring community</b><br></h3>The Risk Management Professional 2 is responsible for leading and executing quality audits within the CenterWell Utilization Management (UM) program, ensuring compliance with regulatory requirements, including CMS and NCQA standards.<br><br>This role is heavily focused on audit accuracy, data analysis, and identification of risks and trends, with an emphasis on leveraging Power BI and Power Apps to support audit processes, reporting, and performance monitoring.<br><br>The successful candidate will bring deep expertise in clinical criteria and regulatory guidance (e.g., Medicare Manuals, NCDs, LCDs, coverage policies, MCG) and demonstrate a strong passion for quality and continuous improvement. This role requires the ability to translate audit findings into meaningful insights, identify root causes, and support program audit readiness from a clinical and research-based perspective.<br>An active, unrestricted Registered Nurse (RN).<h3>Key Responsibilities</h3><ul><li>Conduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policies</li><li>Evaluate clinical decision-making and appropriate application of criteria across inpatient, outpatient, home health, and post-acute services</li><li>Leverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areas</li><li>Utilize Power Apps to support audit workflows, tracking, and data collection processes</li><li>Analyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadership</li><li>Perform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gaps</li><li>Demonstrate strong familiarity with clinical criteria sources, including:<ul><li>Medicare Manuals</li><li>National Coverage Determinations (NCDs)</li><li>Local Coverage Determinations (LCDs)</li><li>Plan coverage policies</li><li>MCG guidelines</li></ul></li><li>Support program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness from a regulatory and research-based perspective</li><li>Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings</li><li>Demonstrate a high level of attention to detail and a strong commitment to quality and accuracy</li><li>Translate complex data into actionable insights and recommendations for stakeholders</li><li>Present audit findings, risks, and trend analyses confidently to leadership and cross-functional teams</li></ul><h3><br><b>Use your skills to make an impact </b><br></h3><h3>Required Qualifications</h3><ul><li>Active, unrestricted Registered Nurse (RN)</li><li>Extensive experience in utilization management, clinical auditing, and/or quality assurance</li><li>Strong knowledge of CMS, NCQA, and regulatory/accreditation requirements<