(RN)Auditor, Healthcare Services - NCQA

Job Title

Provides support for healthcare services clinical auditing activities.

Job Summary

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. This role supports the New Mexico Turquoise Care Contract.

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

Prior experience in clinical review/auditing of care management.

Familiarity with the New Mexico Turquoise Care Contract, NCQA (National Committee for Quality Assurance) auditing and performance standards or IPRO.

Analytical ability to review data and determine quality trends.