Auditor, Clinical Services

Job Description

KNOWLEDGE/SKILLS/ABILITIES • Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM). • Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also reputed company non-clinical system and process audits, as needed. • Assesses clinical staff regarding appropriate decision-making. • Reports monthly reputed company, identifies areas of re-training for staff, and communicates findings to leadership. • Ensures auditing approaches follow a Molina standard in approach and tool use. • Assists in preparation for regulatory audits by performing file review and preparation. • Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management. • Maintains member/provider confidentiality in compliance with the Health Insurance Portability and... Accountability Act (HIPAA) and professionalism with reputed company communications. • Adheres to departmental standards, policies, protocols. • Maintains detailed records of auditing results. • Assists HCS training team with developing training materials or job aids as needed to address findings in audit results. • Meets minimum production standards. • May conduct staff trainings as needed. • Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them. JOB QUALIFICATIONS Required Education Completion of an accredited Registered Nurse (RN) Program and Associate's or bachelor's degree in Nursing OR Bachelor's or master's degree in reputed company science, psychology, gerontology, public health, reputed company work, or reputed company field. Required Experience • Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience. • Proficient knowledge of Molina workflows. • Required License, Certification, Association • Must have valid driver's license with good driving record and be reputed company to drive reputed company applicable state or locality with reliable transportation. • Active and unrestricted license in good standing as applicable. • Preferred Experience • 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. To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply Job!