Healthcare Services Auditor (RN) Clinical Quality Performance

Molina Healthcare

28d•$29 - $68

About The Position

Job Summary: Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements, accreditation standards and organizational performance standards - ensuring quality compliance and desired member outcomes and effective clinical operations. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties Conducts audits, identify gaps in performance, and collaborates with clinical and operational leaders to strengthen processes, support corrective actions, and advance overall clinical quality performance. Monitor Key Performance Indicators (KPIs) and quality metrics to assess clinical performance and identify trends or areas for improvement. Tracks performance against audit thresholds and escalates risk or patterns of non-compliance to leadership. Support readiness for accreditation surveys and regulatory audits through documentation validation and process review. Prepares accurate and timely audit reports summarizing outcomes, findings and recommended corrective actions. 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/organizational guidelines and requirements. May also perform non-clinical system and process audits as needed. Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met. • Assesses clinical staff regarding appropriate clinical decision-making. • 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.
Registered Nurse (RN). License must be active and restricted in state of practice.
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.
KPI Performance Oversight Experience is a plus.

Responsibilities

Conducts audits, identify gaps in performance, and collaborates with clinical and operational leaders to strengthen processes, support corrective actions, and advance overall clinical quality performance.
Monitor Key Performance Indicators (KPIs) and quality metrics to assess clinical performance and identify trends or areas for improvement.
Tracks performance against audit thresholds and escalates risk or patterns of non-compliance to leadership.
Support readiness for accreditation surveys and regulatory audits through documentation validation and process review.
Prepares accurate and timely audit reports summarizing outcomes, findings and recommended corrective actions.
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/organizational guidelines and requirements.
May also perform non-clinical system and process audits as needed.
Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met.
Assesses clinical staff regarding appropriate clinical decision-making.
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.