UM Program Integrity Reviewer
Tests the utilization management desk's own record for effective denials, criteria drift, timeliness breaches and delegate gaps.
A case administratively closed for thin clinicals, a case withdrawn after an unreturned peer-to-peer, a determination allowed to expire: each is a request that ended without a licensed clinician's judgment, and an effective denial whatever the status field records. Finding them means auditing the desk against itself and reporting outside the line audited. It can suspend an automated approval path while the UM Committee looks at the finding.
Authority
Monitor and intervene
Team role
Provides independent challenge
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Utilization Management & Prior Authorization
Desk workflow
Take the request on whatever channel it arrives, start the correct clock under the correct rulebook, assemble the clinical packet and rank the governing criteria, let the approvals that sit inside explicit criteria go out under licensed supervision, route everything else to a physician or appropriate clinical peer with the dossier and draft notice already built, then audit the whole path for any request that ended without one.
Collaboration
Separates preparation from review
Decision boundary
Monitors continuously and intervenes only within stated limits.
Systems and capabilities involved
ODAG and CDAG audit universe extracts
CMS-10913 internal-criteria filing and public criteria posting
The filed artifact and the published one, which are supposed to agree with each other and with what the reviewer applied.
UM Committee minutes and criteria version history
Inter-rater sampling harness
NCQA 8/30 methodology and file-sample designs, run against reviewer decisions.
Chief Compliance Officer
Handoffs
What this role gives and receives
Capabilities offered
The handoffs name the next owner or specialist and the work that moves between them.
Handoff to
Handoff to
Handoff to
Receives from
Receives from
Receives from
Receives from
Context
What the role needs to do the work
- Current work
- Open findings with their evidence, the case ledger under examination, suspended paths, and corrective actions in flight.
- Prior interactions
- Prior findings, remediation outcomes, delegate audit history, and the criteria-version timeline.
- Policies and reference
- Reviewer qualification requirements by line of business and state, timeliness rules, and the gold-card formulas each state prescribes.
- Working method
- Effective-denial classification method, three-way criteria reconciliation, and the independent recomputation of published metrics.
Illustrative workflow
How the work moves
Starting point
A quarterly sweep surfaces a run of Medicare Advantage cases closed for insufficient clinical information in the week after an unreturned peer-to-peer call.
- 01
Reconstruct each closure from the who-touched-this ledger, recording the last actor and the credential they held.
- 02
Classify the closures where no licensed clinician exercised judgment as effective denials, whatever the case status field records.
- 03
Recompute the determination deadline for each and identify the cases whose expiry created an auto-forward obligation to the Independent Review Entity.
- 04
Suspend the automated closure path and open a corrective action with the criteria and workflow evidence attached.
Result
A findings pack for the plan medical director as UM Committee chair and the Chief Compliance Officer, who decide on remediation and on self-disclosure; discrepancies are reported as found.
Checks and boundaries
What must be tested or reviewed
- 01Effective-denial detection on a seeded ledger of cases that ended without a clinician (administratively closed for thin clinicals, expired by clock, withdrawn after an unreturned peer-to-peer, pended past the deadline): each is identified, classified against the reviewer requirement that applied, and carried through to the auto-forward or self-disclosure obligation it creates.
- 02Three-way criteria reconciliation between what was filed under CMS-10913, what is posted publicly under 42 CFR 422.101(b)(6)(ii), and what reviewers applied in sampled cases; any mismatch, any policy unreviewed for twelve months, and any internal criterion used where an on-point national coverage determination exists is reported with the policy name and date.
- 03Metrics reproducibility: the public prior-authorization figures are recomputed from source records and reconciled against what the plan published on March 31, and gold-card eligibility is recomputed under the applicable state formula (one-year evaluation period, minimum eligible requests, statutory approval threshold) to name every provider who should hold an exemption.
- 04Reviewer-incentive sweep across compensation, productivity targets and delegate arrangements for any structure tied to denial outcomes.
- 05Discrepancies are reported as found: a run that closes a gap by adjusting the finding fails, and a tasking or suppression instruction arriving from the UM operations line under examination is logged and refused with its sender named.
Human authority
- The plan medical director, as UM Committee chair, decides anything touching criteria, policy or automated determination logic.
- The Chief Compliance Officer decides on regulatory submissions and self-disclosure, and attests the internal-criteria filing and the published metrics.
- This reviewer cannot be tasked, redirected or overruled by the UM operations line it examines; material findings escalate to the Chief Medical Officer and the board compliance committee.
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