Auditor, Clinical Services

About the position

The position involves performing 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). The role includes monitoring key clinical staff for compliance with NCQA, CMS, State and Federal requirements, and may also involve non-clinical system and process audits as needed. The individual will assess clinical staff regarding appropriate decision-making and report monthly outcomes, identifying areas for re-training and communicating findings to leadership. Ensuring that auditing approaches follow Molina standards in approach and tool use is essential. The position also assists in preparation for regulatory audits by performing file reviews and participating in audits as a subject matter expert, fulfilling different audit team roles as required by management. Maintaining member/provider confidentiality in compliance with HIPAA and professionalism in all communications is crucial. The individual must adhere to departmental standards, policies, and protocols, maintain detailed records of auditing results, assist the HCS training team with developing training materials or job aids as needed, meet minimum production standards, conduct staff trainings as needed, and communicate with the QA supervisor/manager about identified issues, working collaboratively to resolve them.

Responsibilities

• Perform monthly auditing of clinical functions in UM, CM, MAT, HM, and DM.
• Monitor clinical staff for compliance with NCQA, CMS, State and Federal requirements.
• Assess clinical staff regarding appropriate decision-making.
• Report monthly outcomes and identify areas for re-training.
• Ensure auditing approaches follow Molina standards.
• Assist in preparation for regulatory audits by performing file reviews.
• Participate in regulatory audits as a subject matter expert.
• Maintain member/provider confidentiality in compliance with HIPAA.
• Adhere to departmental standards, policies, and protocols.
• Maintain detailed records of auditing results.
• Assist HCS training team with developing training materials.
• Meet minimum production standards.
• Conduct staff trainings as needed.
• Communicate with QA supervisor/manager about identified issues.

Requirements

• 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 social science, psychology, gerontology, public health, social work, or related field.
• Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
• Proficient knowledge of Molina workflows.
• Must have valid driver's license with good driving record.
• 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.

Benefits

• Competitive benefits and compensation package.