Auditor, Healthcare Services (RN)
Job Description
JOB DESCRIPTION
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Job Summary
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Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements - ensuring quality compliance and desired member outcomes. Contributes to overarching strategy to provide quality and cost-effective member care.
\n Essential Job Duties
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• Performs audits in utilization management, care management, member assessment, behavioral health, and/or other clinical teams, and monitors clinical staff for compliance with National Committee for Quality Assurance, Centers for Medicare and Medicaid Services (CMS), and state/federal guidelines and requirements. May also perform non-clinical system and process audits as needed.
\n • Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met.
\n • Assesses clinical staff regarding appropriate clinical decision-making.
\n • Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to leadership.
\n • Ensures auditing approaches follow a Molina standard in approach and tool use.
\n • Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA), and professionalism in all communications.
\n • Adheres to departmental standards, policies and protocols.
\n • Maintains detailed records of auditing results.
\n • Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results.
\n • Meets minimum production standards related to clinical auditing.
\n • May conduct staff trainings as needed. • Communicates with quality and/or healthcare services leadership regarding issues identified, and works collaboratively to subsequently resolve/correct.
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Required Qualifications
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• At least 2 years health care experience, with at least 1 year experience in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience.
\n • Registered Nurse (RN). License must be active and restricted in state of practice.
\n • Strong attention to detail and organizational skills.
\n • Strong analytical and problem-solving skills.
\n • Ability to work in a cross-functional, professional environment.
\n • Ability to work on a team and independently.
\n • Excellent verbal and written communication skills.
\n • Microsoft Office suite/applicable software program(s) proficiency.
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Preferred Qualifications
\n • Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience.
\n To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
\n Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Pay Range: $33.4 - $67.97 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.