Auditor, Clinical Services

JOB DESCRIPTION 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 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.

• 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 utilization management, 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

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

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To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $29.05 - $56.64 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.