Auditor, Healthcare Services (RN) (Remote) Must Live In Nebraska

Clinical Auditor Position

This position will offer remote work flexibility, but the selected candidate must reside in Nebraska.

Opportunity for a Registered Nurse who has a US license in good standing to join our Medicaid Team as a Clinical Auditor. The person filling this role will be an instrumental part of the team work to align the Medicaid Team compliance guidelines with those followed by our corporate teams. Knowledge and experience working with NCQA standards is vital to success in this role. The preferred candidate will have 3 5 years of experience in a MCO and at least 2 years of clinical auditing and/or review experience. Mastery of Microsoft Office, especially Excel, PowerPoint will also be skill sets we are seeking. Hours are Monday Friday, 8AM 5PM in your time zone.

Job Summary

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.

Essential Job Duties

Performs audits in 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. Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met. Assesses clinical staff regarding appropriate clinical decision-making. Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to leadership. Ensures auditing approaches follow a Molina standard in approach and tool use. Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA), and professionalism in all communications. Adheres to departmental standards, policies and protocols. Maintains detailed records of auditing results. Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results. Meets minimum production standards related to clinical auditing. May conduct staff trainings as needed. Communicates with quality and/or healthcare services leadership regarding issues identified and works collaboratively to subsequently resolve/correct.

Required Qualifications

At least 2 years health care experience, with at least 1 year experience in care management, and/or managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and restricted in state of practice. Strong attention to detail and organizational skills. Strong analytical and problem-solving skills. Ability to work in a cross-functional, professional environment. Ability to work on a team and independently. Excellent verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

Care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience.