Clinical Services Auditor

2 weeks ago


Long Beach, California, United States Molina Healthcare Full time
Job Overview

Essential Knowledge, Skills, and Abilities
  • Conducts monthly evaluations of registered nursing and various clinical operations within Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM).
  • Ensures adherence of key clinical personnel to NCQA, CMS, State, and Federal regulations. May also execute non-clinical system and process evaluations as necessary.
  • Evaluates clinical personnel regarding sound decision-making practices.
  • Documents monthly results, identifies areas requiring re-training for staff, and communicates insights to leadership.
  • Guarantees that auditing methodologies align with Molina standards in both approach and tool utilization.
  • Aids in the preparation for regulatory assessments by conducting file reviews and necessary preparations.
  • Engages in regulatory assessments as a subject matter expert, fulfilling various roles within the audit team as directed by management.
  • Upholds member/provider confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and maintains professionalism in all communications.
  • Complies with departmental standards, policies, and protocols.
  • Keeps meticulous records of auditing outcomes.
  • Collaborates with the HCS training team to develop training materials or job aids as needed to address audit findings.
  • Meets established production benchmarks.
  • May facilitate staff training sessions as required.
  • Communicates with QA supervisors/managers regarding identified issues and collaborates to resolve them.
Qualifications

Required Education

Completion of an accredited Registered Nurse (RN) Program along with an Associate's or Bachelor's degree in Nursing, or a Bachelor's or Master's degree in social science, psychology, gerontology, public health, social work, or a related discipline.

Required Experience
  • A minimum of two years of experience in UM, CM, MAT, HM, DM, and/or managed care.
  • Comprehensive knowledge of Molina workflows.
  • Required License, Certification, Association
  • Possession of a valid driver's license with a clean driving record and the ability to drive within the applicable state or locality using reliable transportation.
  • Active and unrestricted license in good standing as applicable.
  • Preferred Experience
  • 3-5 years of experience in case management, disease management, or utilization management within managed care, medical, or behavioral health environments.
  • Two years of clinical auditing/review experience.
Additional Information

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

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