Nurse (Health Care)

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. This role supports the New Mexico Turquoise Care Contract.

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. Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met.

• Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to leadership.
• 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.
• Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results.
• Communicates with quality and/or healthcare services leadership regarding issues identified, and works collaboratively to subsequently resolve/correct.

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). Microsoft Office suite/applicable software program(s) proficiency.

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.
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.