• Provides clinical oversight and management of UM audit activities • Leads and coordinates UM audit activities • Audits UM activities to ensure compliance with established timeframes and standards of performance in accordance with the National Committee for Quality Assurance (NCQA), the Department of Health (DOH), Centers for Medicare and Medicaid Services (CMS), and other state and federal regulatory requirements • Prepares and presents audit findings to UM leadership, corporate and Medicare compliance and/or the Quality and Accreditation team as appropriate • Ensures sample size and frequency of audits is appropriate for the population • Monitors vendor compliance activities • Responsible for CMS reporting requirements including: Part C Organization Determinations, Appeals, and Grievances (ODAG) report review and auditing for Capital and delegated UM vendors