Auditor, Clinical Services (KY RN License Required)

Molina Healthcare

417d • $52,166 - $107,099

About The Position

The Auditor for Clinical Services at Molina Healthcare is responsible for conducting monthly audits of clinical functions within various departments such as Utilization Management, Case Management, and Disease Management. This role ensures compliance with regulatory standards and prepares for audits while maintaining confidentiality and professionalism. The auditor will also assist in training staff and developing materials based on audit findings.

Requirements

• Completion of an accredited Registered Nurse (RN) Program and Associate's or bachelor's degree in Nursing OR Bachelor's or master's degree in social science, psychology, gerontology, public health, social work, or related field.
• Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
• Proficient knowledge of Molina workflows.
• Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
• Active and unrestricted license in good standing as applicable.

Nice To Haves

• 3-5 years of experience in case management, disease management or utilization management in managed care, medical or behavioral health settings.
• Two years of clinical auditing/review experience.

Responsibilities

• Perform monthly auditing of registered nurse and other clinical functions in Utilization Management, Case Management, Member Assessment Team, Health Management, and Disease Management.
• Monitor key clinical staff for compliance with NCQA, CMS, State and Federal requirements.
• Assess clinical staff regarding appropriate decision-making.
• Report monthly outcomes, identify areas of re-training for staff, and communicate findings to leadership.
• Ensure auditing approaches follow Molina standards in approach and tool use.
• Assist in preparation for regulatory audits by performing file review and preparation.
• Participate in regulatory audits as a subject matter expert and fulfill different audit team roles as required by management.
• Maintain member/provider confidentiality in compliance with HIPAA and professionalism with all communications.
• Adhere to departmental standards, policies, and protocols.
• Maintain detailed records of auditing results.
• Assist HCS training team with developing training materials or job aids as needed to address findings in audit results.
• Meet minimum production standards.
• Conduct staff trainings as needed.
• Communicate with QA supervisor/manager about issues identified and work collaboratively to resolve/correct them.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree