Auditor de Utilización Médica

About the role

The Medical Utilization Auditor is responsible for reviewing clinical records, ensuring compliance with applicable laws, regulations, and medical‑plan requirements, and supporting the delivery of high‑quality care across Costa Salud Community Health Centers.

Key responsibilities

• Conduct clinical evaluations and audits of medical records.
• Monitor and assess medical utilization within the facilities.
• Ensure compliance with insurer and medical‑plan criteria and requirements.
• Maintain continuous, effective communication with physicians and administrative staff.
• Perform other related tasks as needed.

Required profile

• Bachelor’s or Master’s degree in Nursing from an accredited university (preferred).
• At least 2 years of experience auditing medical plans, preferably in health centers or hospitals.
• Bilingual proficiency in Spanish and English.
• Current professional credentials.
• Strong knowledge of HEDIS, EPSDT, CMS, RAF, AHA, CHRA, E‑PASS, ICD‑10, HIPAA and care transition processes.
• Proficiency with Microsoft Office and medical‑plan platforms.

Required skills

• HEDIS
• EPSDT
• CMS
• RAF
• AHA
• CHRA
• E‑PASS
• ICD‑10
• HIPAA
• Microsoft Office