Utilization Management Compliance Specialist

The Utilization Management (UM) Compliance Specialist is responsible for ensuring that all Utilization Management operations comply with applicable federal and state regulatory requirements, accreditation standards, and delegated health plan contractual obligations. This role serves as the primary compliance and audit resource for Utilization Management, supporting the Managed Services Organization (MSO) through proactive policy and procedure management, audit preparation, regulatory survey support, report submission, corrective action planning, staff training, and continuous compliance improvement. This role drives audit readiness, leads and/or coordinates internal and external audits, manages corrective action plans (CAPs), oversees timely health plan report generation and submissions, and delivers ongoing training to UM teams. The Utilization Management Compliance Specialist partners cross‑functionally with UM leadership, Case Management, Medical Directors, Quality, Compliance, Delegation Oversight, Grievances & Appeals, Provider Relations, Network Management, IT/Data, and contracted health plans. This role promotes a strong culture of compliance, continuous improvement, and ensures that Case Management programs operate in alignment with CMS, DHCS, DMHC, MCG, and other governing bodies, consistent with industry best practices and the expectations of high‑performing MSOs and integrated health systems.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

• Excellent verbal and written communication.
• Develop and maintain effective working relationships with all levels of staff, community agencies, providers, and members.
• Maintain an understanding of current CPT, ICD-10 and HCPCS codes and continual updates to knowledge base regarding the codes.
• Working knowledge of regulations/standards governing CM (e.g. Medicare/Medicaid, HIPAA, NCQA standards, MCG principles) and payer/delegation requirements, as applicable to the organization’s lines of business.
• Strong project management, organization, and follow‑through; able to manage multiple audits and deadlines in a fast‑paced environment.
• Analytical skills for file reviews, data validation, root cause analysis, and trend analysis; proficiency with Microsoft 365 (Word, Excel, PowerPoint, SharePoint/Teams).
• Utilize prior authorization protocols to determine when to refer matters to a licensed staff person.
• Excellent written and verbal communication; facilitation and training skills; ability to influence without authority and work cross‑functionally.
• Familiar with EHR and electronic healthcare benefit management software (e.g. EZ-CAP, Epic).
• Ability to take initiative in analyzing problems, developing a solution with a win-win approach.
• Must be familiar with Health Plan benefit verification.
• Must have knowledge of medical terminology.

Required:

• High School Graduate or equivalent certification.
• Active California LVN license
• Minimum of two (2) years’ experience in a managed care or health plan environment.
• Minimum of two (2) years’ experience in UM referral management services.
• Knowledge of medical terminology.

Preferred:

• Passed the Bilingual Fluency Assessment for Clinicians (BFAC Certified) by Language Line Solutions.