About the role
JOB DESCRIPTION Job Summary
Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements - ensuring quality compliance and desired member outcomes. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- 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 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.
Required Qualifications
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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.
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Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
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Strong attention to detail and organizational skills.
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Strong analytical and problem-solving skills.
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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.
Preferred Qualifications
- Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
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