Clinical Services Auditor
2 weeks ago
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.
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.
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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