Auditor, Long-Term Services & Supports (RN) (must reside in WI)

Molina Healthcare•Long Beach, WI

About The Position

Provides support for Healthcare Services clinical long-term services and supports (LTSS) auditing activities. Performs risk-focused audits and analyses to identify member health and safety concerns, emerging patterns, and gaps in risk identification, mitigation, documentation, escalation, and follow-up. Contributes to an overarching strategy to provide quality and cost-effective member care. The position must reside in Wisconsin.

Requirements

At least 3 years of healthcare experience, preferably in care management, utilization management, and/or managed care, and at least 2 years of experience in LTSS, quality improvement, audit, and/or member health and safety activities, or an equivalent combination of relevant education and experience.
Registered Nurse (RN); license must be active and unrestricted in the state of practice.
Demonstrated experience working with data, reports, or audit results to identify trends, outliers, and opportunities for improvement.
Strong analytical and problem-solving skills.
Strong attention to detail and organizational skills.
Ability to work in a cross-functional, professional environment.
Ability to work on a team and independently.
Strong verbal and written communication skills.
Proficiency in Microsoft Office suite or applicable software programs.
Microsoft Excel proficiency, including organizing, reconciling, filtering, and analyzing data.
In some states, a bachelor's degree in a healthcare-related field may be required, depending on state or contractual requirements.
Must reside in Wisconsin.

Nice To Haves

Care management, utilization management, behavioral health, quality, and/or LTSS clinical review or auditing experience.
Experience with Medicaid long-term care populations, member-centered planning, critical incidents, transitions of care, or high-risk member oversight.
Certified Professional in Healthcare Quality (CPHQ), Certified Internal Auditor (CIA), or another related quality, audit, data, or risk certification.
Experience with dashboards, data visualization, statistical analysis, or reporting tools.

Responsibilities

Conduct retrospective, concurrent, and targeted audits of care management records, assessments, member-centered plans, risk reduction agreements, critical incidents, functional level service review assessments, residential placement activities, home and community-based services (HCBS), care coordination, case notes, hospitalizations, workflows, reports, and other information relevant to member health and safety.
Review LTSS, HCBS, care management, and utilization management activities to ensure risks are identified across the continuum of care.
Facilitate reviews to ensure risks are consistently identified, linked to appropriate mitigation strategies, clearly and comprehensively documented, followed up on timely, and escalated when unresolved or time sensitive.
Identify trends related to residential placement, HCBS service delivery, critical incidents, care coordination, provider performance, and other factors that may impact member health and safety.
Use clinical, operational, critical incident, care management, utilization management, and quality information to identify patterns, combinations of factors, outliers, and member cohorts that may signal increased vulnerability.
Analyze audit results and internal metrics across care management and utilization management units, departments, regions, member populations, time periods, residential settings, and other service delivery systems to identify recurring or emerging member health and safety risks.
Validate data quality and maintain traceability of findings to source documentation.
Report outcomes, identify staff retraining needs, and communicate findings to leadership.
Document findings, risk level, recommended action, accountable owner, due date, status, escalation point, and evidence needed to confirm completion.
Conduct follow-up reviews to verify required corrections or interventions occurred and evaluate whether actions improved the related operational measure, member outcome, or risk condition.
Ensure auditing approaches follow a Molina standard in approach and tool use.
Maintain member and provider confidentiality in compliance with HIPAA, demonstrate professionalism in communications, and adhere to departmental standards, policies, and protocols.
Maintain detailed records of auditing results.
Assist with developing training materials or job aids as needed to address audit findings.
Meet minimum production standards related to non-clinical auditing.
Conduct staff training as needed.
Communicate with Quality and Healthcare Services leadership regarding identified issues and collaborate to resolve or correct them.