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Clinical Services Auditor

2 months ago

Riverside, United States Molina Healthcare Remote Work Freelance Full time

For this position we are seeking a (LVN/LPN) Nurse with previous experience in Case management, Acute Care, Concurrent Review/Utilization Review/Utilization Management and knowledge of Interqual/MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

You will be performing audits for: case management, pediatrics and adults, UM audits, transition of care, and ECM.

Home office with private desk area, and high speed Internet connectivity required.

WORK SCHEDULE: 5 days/daytime work schedule M - F 8:00AM to 5:00PM PACIFIC. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our interview process.

KNOWLEDGE/SKILLS/ABILITIES

  • Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.

  • Audits for clinical gaps in care from a medical and/or behavioral 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 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 with all communications.

  • Adheres to departmental standards, policies, protocols.

  • Maintains detailed records of auditing results.

  • Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.

  • Meets minimum production standards

  • May conduct staff trainings as needed

  • Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them.

  • 15% travel required.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program and/or Associate's or bachelor's degree in Health related field.

Required Experience

  • Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.

  • Proficient knowledge of Molina workflows.

Required License, Certification, Association

  • Active, unrestricted State Licensed Vocational Nurse or Practical Nurse (LVN or LPN) in good standing.

  • Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Experience

More than one-year managed care experience. One year of UM, CM, DM auditing experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the Intranet job listing.

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

Pay Range: $21.6 - $46.81/HOURLY

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