Auditor, Healthcare Services - Must reside in Michagan, remote position

Molina Healthcare•Long Beach, MI

1d•Remote

About The Position

JOB DESCRIPTION Job Summary 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. Essential Job Duties 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. May also perform non-clinical system and process audits as needed. Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to 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 in all communications. Adheres to departmental standards, policies and protocols. Maintains detailed records of auditing results. Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results. Meets minimum production standards related to clinical auditing. May conduct staff trainings as needed. Communicates with quality and/or healthcare services leadership regarding issues identified, and works collaboratively to subsequently resolve/correct.

Requirements

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.
RN or Social Worker Clinical licensure and/or certification required in the State of Michigan, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in State of Michagan.
Strong attention to detail and organizational skills.
Strong analytical and problem-solving skills.
Ability to work in a cross-functional, professional environment.
Ability to work on a team and independently.
Excellent verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience.

Responsibilities

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. May also perform non-clinical system and process audits as needed.
Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to 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 in all communications.
Adheres to departmental standards, policies and protocols.
Maintains detailed records of auditing results.
Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results.
Meets minimum production standards related to clinical auditing.
May conduct staff trainings as needed.
Communicates with quality and/or healthcare services leadership regarding issues identified, and works collaboratively to subsequently resolve/correct.