Molina Healthcare Clinical Services Auditor (RN) in Midvale, Utah
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) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed. • Audits for clinical gaps in care from a medical and/or behavioral perspective to ensure member needs are being met. • Assesses registered nurses and other clinical staff regarding appropriate clinical decision-making. • Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings 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 with all 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. • 15% travel required.
Required Education Completion of an accredited Registered Nurse (RN) Program and an Associate's or Bachelor's Degree in Nursing. Required Experience Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
Proficient knowledge of Molina workflows. Required License, Certification, Association Active, unrestricted State Registered Nurse (RN) License in good standing.
Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings.
One year of auditing/ clinical review experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job: *Healthcare Services
Organization: *Health Plans
Title: Clinical Services Auditor (RN)
Requisition ID: 1901592