Remote Auditor, Clinical Services - RN preferred

Molina Healthcare

402d • $54,933 - $128,523 • Remote

About The Position

The Remote Auditor, Clinical Services position at Molina Healthcare is focused on auditing clinical functions within various healthcare management areas, including Utilization Management, Case Management, and Disease Management. The role involves ensuring compliance with regulatory standards, preparing for audits, and providing training and support to clinical staff based on audit findings.

Requirements

• Completion of an accredited Registered Nurse (RN) Program and an Associate's or Bachelor's degree in Nursing OR a Bachelor's or Master's degree in social science, psychology, gerontology, public health, social work, or a related field.
• Minimum two years of experience in Utilization Management, Case Management, Member Assessment Team, Health Management, Disease Management, and/or managed care.
• Proficient knowledge of Molina workflows.
• Must have a valid driver's license with a good driving record and be able to drive within applicable state or locality with reliable transportation.
• Active and unrestricted license in good standing as applicable.

Nice To Haves

• 3-5 years of experience in case management, disease management, or utilization management in managed care, medical, or behavioral health settings.
• Two years of clinical auditing/review experience.

Responsibilities

• Perform monthly auditing of registered nurse and other clinical functions in Utilization Management, Case Management, Member Assessment Team, Health Management, and Disease Management.
• Monitor key clinical staff for compliance with NCQA, CMS, State and Federal requirements.
• Assess clinical staff regarding appropriate decision-making.
• Report monthly outcomes, identify areas for re-training, and communicate findings to leadership.
• Ensure auditing approaches follow Molina standards in approach and tool use.
• Assist in preparation for regulatory audits by performing file review and preparation.
• Participate in regulatory audits as a subject matter expert and fulfill different audit team roles as required by management.
• Maintain member/provider confidentiality in compliance with HIPAA and professionalism in communications.
• Adhere to departmental standards, policies, and protocols.
• Maintain detailed records of auditing results.
• Assist HCS training team with developing training materials or job aids as needed to address findings in audit results.
• Meet minimum production standards.
• Conduct staff trainings as needed.
• Communicate with QA supervisor/manager about issues identified and work collaboratively to resolve/correct them.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree