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.