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

Molina Healthcare•Long Beach, WI

About The Position

Provides support for Healthcare Services clinical and non-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 role conducts 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. It reviews LTSS, HCBS, care management, and utilization management activities to ensure risks are identified across the continuum of care and addressed consistently through mitigation, documentation, timely follow-up, and escalation. The auditor identifies trends and analyzes clinical, operational, critical incident, care management, utilization management, and quality information to detect patterns, outliers, and member cohorts that may indicate increased vulnerability. The role validates data quality, traces findings to source documentation, reports outcomes and staff retraining needs to leadership, documents audit findings and corrective actions, and conducts follow-up reviews to verify completion and assess impact. It also supports training materials and job aids, may conduct staff training, maintains confidentiality in compliance with HIPAA, and follows Molina standards, departmental policies, protocols, and production requirements. The employee must reside in Wisconsin.

Requirements

Must reside in Wisconsin.
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, or member health and safety activities; an equivalent combination of relevant education and experience is acceptable.
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 both on a team and independently.
Strong verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs.
Microsoft Excel proficiency, including organizing, reconciling, filtering, and analyzing data.
A bachelor's degree in a healthcare-related field may be required in some states, depending on state or contractual requirements.

Nice To Haves

Care management, utilization management, behavioral health, quality, and/or LTSS clinical or non-clinical review and 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, HCBS and 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, connected to appropriate mitigation strategies, clearly documented, followed up on promptly, 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 affecting 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 units, departments, regions, member populations, time periods, residential settings, and other service delivery systems to identify recurring or emerging 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 and evaluate whether actions improved operational measures, member outcomes, or risk conditions.
Follow Molina standards for auditing approaches and tool use.
Maintain member and provider confidentiality in compliance with HIPAA, communicate professionally, and follow departmental standards, policies, and protocols.
Maintain detailed records of audit results and meet minimum production standards for non-clinical auditing.
Assist with developing training materials or job aids to address audit findings and conduct staff training as needed.
Communicate identified issues to Quality and Healthcare Services leadership and collaborate to resolve or correct them.