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

Molina Healthcare•Long Beach, CA

About The Position

Leads and manages a team conducting clinical and non-clinical audits of long-term services and supports (LTSS) operations, investigations, and risk assessment activities. Applies internal audit practices to evaluate operating effectiveness and recommend training enhancements and process improvements, focusing on member health and safety, proactive risk identification and mitigation, follow-up, and evaluation of intervention effectiveness. Contributes to the strategy for delivering quality, cost-effective member care. The role oversees risk-focused audits across residential placements, home and community-based services (HCBS), member-centered planning, critical incidents, utilization management, and care management operations. It establishes audit priorities, approaches, measures, thresholds, review cadence, and escalation criteria in collaboration with relevant functions; analyzes findings and trends across teams, departments, regions, member cohorts, and risk indicators; and develops reporting, dashboards, and trend analyses. The Manager translates audit results and health and safety concerns into recommendations, presents findings and corrective-action status to operational and executive stakeholders, and monitors whether corrective and preventive actions are effective. As a hands-on leader, the role supervises daily work, hires and develops staff, and is accountable for team performance, staffing, service levels, productivity, and department goals. The position requires residence in Wisconsin.

Requirements

At least 7 years of healthcare experience, including care management, utilization management, behavioral health, and/or managed care operations; auditing experience is preferred within this qualification.
At least 3 years of experience in LTSS, quality improvement, and/or member health and safety oversight, or an equivalent combination of relevant education and experience.
At least 1 year of healthcare management or leadership experience.
One of the following credentials: RN, LVN, LPN, LCSW, LMFT, LPCC, or LMSW. Clinical licensure and/or certification is required only when required by state contract, regulation, business operating model, or state board licensing mandates; any license held must be active and unrestricted in the state of practice.
Experience developing or managing risk-based audit, monitoring, or quality review programs and translating findings into corrective or preventive action.
Ability to analyze data from multiple sources, identify patterns and outliers, and communicate actionable risk findings to operational and executive leaders.
Strong analytics and problem-solving abilities.
Strong organizational and time-management skills.
Ability to multitask and meet project deadlines.
Strong attention to detail.
Ability to build relationships and collaborate cross-functionally.
Ability to maintain a high level of confidentiality.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs.
Must reside in Wisconsin.

Nice To Haves

Managed care operations and/or clinical experience.
Care management, utilization management, behavioral health, and/or LTSS clinical review or auditing experience.
Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM), Certified Internal Auditor (CIA), or another related quality, audit, clinical, or risk certification.
Experience with Medicaid long-term care populations, member-centered planning, critical incidents, transitions of care, or high-risk member oversight.
Experience with dashboards, data visualization, statistical analysis, or reporting tools used to identify and monitor trends.
A bachelor's degree in a healthcare-related field may be required in some states, depending on state or contractual requirements.

Responsibilities

Oversee the LTSS audit team and audits involving member health and safety, including residential placements, HCBS, member-centered planning, critical incidents, utilization management, and care management delivery and support operations.
Establish and maintain a risk-focused audit program using member-level and aggregate clinical, operational, critical incident, and care management information to identify emerging or recurring health and safety risks.
Define risk-based audit priorities, sampling approaches, measures, thresholds, review cadence, and escalation criteria with Quality, Care Management, Utilization Management, Member Health and Safety, and other applicable functions.
Direct audits of risk identification, mitigation, documentation, member involvement, follow-up, escalation, and monitoring of intervention effectiveness.
Ensure audit findings distinguish isolated corrections from recurring process, workflow, knowledge, technology, staffing, or system-level risks.
Aggregate and analyze findings across care management and utilization management units, departments, regions, member cohorts, and risk indicators to identify broader patterns.
Develop and maintain reporting, dashboards, and trend analyses concerning member health and safety, residential placement activity, HCBS services, critical incidents, risk mitigation, and corrective actions.
Translate audit results and trend analyses into actionable recommendations and work with operational leaders to monitor corrective and preventive action implementation and effectiveness.
Present audit findings, health and safety trends, emerging risks, and corrective-action status to operational leaders, executive leadership, and internal stakeholders; facilitate discussion of priorities, mitigation, escalation, resources, and next steps.
Contribute to operational workflow improvements and escalate observations and trends to support continual improvement, member outcomes, and health plan performance.
Monitor corrective and preventive actions and assess whether they improve operational measures, member outcomes, risk conditions, or recurrence patterns.
Maintain professional relationships with internal and external customers and identify improvement opportunities.
Protect member and provider confidentiality in compliance with HIPAA and communicate professionally.
Promote interdepartmental and multidisciplinary collaboration to enhance continuity of care and quality of services.
Ensure adequate staffing and service levels and monitor staff productivity and other performance indicators to maintain customer satisfaction.
Supervise and coordinate daily activities as a hands-on leader.
Hire, train, develop, and manage the team; remain accountable for team performance and department-specific goals.