Senior Auditor, Delegation Oversight

Molina Healthcare

About The Position

Provides senior level audit support for delegation oversight activities. Responsible for ensuring delegates are complaint with the applicable state, federal, contractual requirements, National Committee for Quality Assurance (NCQA), and Molina requirements for the health plan(s) they support. Identifies risk and non-compliance, issues corrective action, and actively manages the corrective action process to completion reducing and managing Molina's risk.

Requirements

At least 3 years of managed care experience, including at least 2 years of delegation oversight auditing experience, or equivalent combination of relevant education and experience. experience.
Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required.
Ability to collaborate cross-functionally across a highly matrixed organization.
Strong attention to detail and organizational skills.
Strong critical-thinking, and problem-solving/analytical abilities.
Strong interpersonal and verbal/written communication skills.
Microsoft Office suite proficiency (including Excel), and ability to learn/navigate new software programs.

Nice To Haves

Certified Credentialing Specialist (CCS), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), Certified Clinical Coder (CCD), Certified Medical Audit Specialists (CMAS), Certified Professional in Healthcare Management (CPHM) and/or other health care certification/licensure. If licensed, license must be active and unrestricted in state of practice.

Responsibilities

Leads and performs pre-delegation, annual audits, and ensures all components of audit activities comply with contractual, regulatory, and accreditation requirements.
Conducts detailed and focused audits on delegates' policies, procedures, case files and evidence of ongoing monitoring to ensure quality and cost-effective provision of delegated services.
Engages delegate leadership to educate, collaborate, and/or remediate risks to Molina.
Leverages highly skilled analytical insights and experience to identify delegate systemic issues and risks that impact the business; collaborates with health plans and/or corporate departments and other business owners to actively address and mitigate risk to Molina.
Conducts analysis of audit issues to identify root-causes, develops and issues corrective action plans (CAPs), and documents follow-up to ensure successful remediation.
Prepares, tracks and provides audit finding reports in accordance with departmental requirements.
Prepares, submits and presents audit reports to delegation oversight committees.
Presents audit findings to delegates, and makes recommendations for improvements based on audit results.
Collaborates with delegation oversight leadership to develop and maintain assessment tools.
Makes independent decisions on complex issues and project components.
Serves as subject matter expert on policies, regulations, contractual requirements and delegate contracts for the relevant area.
Remains current on applicable regulatory, contractual and accreditation requirements and standards; interprets regulatory, contractual and accreditation changes and assesses their impact on the relevant area.
Conducts outreach to multiple department heads regarding key performance indicator (KPI) data analysis for quarterly meetings.
Provides training and support to new and existing delegation oversight team members.