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

Molina Healthcare•Long Beach, WI

About The Position

Leads and manages a team responsible for clinical and non-clinical audits of Long-Term Services and Supports (LTSS) operations, investigations, and risk assessment activities. Applies internal audit theory and practice to evaluate operational effectiveness and recommend training enhancements and process improvements, with a primary focus on member health and safety, proactive risk identification and mitigation, follow-up, and evaluating intervention effectiveness. Contributes to the strategy for providing quality, cost-effective member care. Oversees risk-focused audits across LTSS service delivery, including residential placements, home and community-based services (HCBS), member-centered planning, critical incidents, utilization management, and care management operations. Establishes audit priorities, sampling approaches, measures, thresholds, review cadence, and escalation criteria with relevant internal functions. Directs review of risk identification and mitigation, documentation, member involvement, follow-up, escalation, and intervention effectiveness. Aggregates findings across teams, departments, regions, member cohorts, and risk indicators to identify emerging or recurring risks. Develops reporting, dashboards, and trend analyses related to member health and safety and translates findings into recommendations. Works with operational leaders to monitor corrective and preventive actions and assess their effectiveness. Presents findings and risk trends to operational and executive leaders and facilitates discussion of priorities, mitigation strategies, escalation, resources, and next steps. Maintains confidentiality and professional relationships, promotes multidisciplinary collaboration and continuous improvement, and supervises the team’s daily activities, staffing, service levels, development, and performance. The role must be based 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 requirement.
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 mandated by a state contract, regulation, business operating model, or state board licensing requirements. Any required license 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.
Demonstrated 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.
A bachelor’s degree in a healthcare-related field may be required in some states, depending on state or contractual requirements.
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.

Responsibilities

Oversee the LTSS audit team and audits related to 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 risks.
Define risk-based audit priorities, sampling approaches, measures, thresholds, review cadence, and escalation criteria in collaboration with relevant functions.
Direct audits of risk identification, mitigation, documentation, member involvement, follow-up, escalation, and intervention effectiveness.
Distinguish isolated corrections from recurring process, workflow, knowledge, technology, staffing, or system-level risks.
Aggregate and analyze findings across units, departments, regions, member cohorts, and risk indicators to identify patterns.
Develop and maintain reporting, dashboards, and trend analyses related to member health and safety, residential placement activity, HCBS services, critical incidents, risk mitigation, and corrective actions.
Translate audit results, trend analyses, and member health and safety concerns into actionable recommendations and monitor corrective and preventive action implementation and effectiveness.
Present audit findings, risk trends, LTSS-related findings, residential placement concerns, HCBS performance issues, emerging risks, and corrective action status to operational leaders, executive leadership, and internal stakeholders.
Ensure reports identify the concern or trend, affected population or process, severity, accountable owners, required action, due date, status, escalation point, and evidence of completion.
Facilitate discussions about priorities, mitigation strategies, escalation needs, resources, and next steps.
Contribute to ongoing operational workflow improvements and escalate observations and trends to support continual improvement, member outcomes, and health plan performance.
Monitor corrective and preventive actions and evaluate whether they improve operational measures, member outcomes, risk conditions, or recurrence patterns.
Maintain professional relationships with internal and external customers and identify opportunities for improvement.
Maintain member and provider confidentiality in compliance with HIPAA and communicate professionally.
Promote interdepartmental and multidisciplinary integration and collaboration to enhance continuity of care and quality of services.
Ensure adequate staffing and service levels and maintain customer satisfaction by monitoring staff productivity and other performance indicators.
Supervise and coordinate daily activities; hire, train, develop, and manage the team; and ensure team performance and achievement of department goals.