Job Description

Provides support for clinical healthcare services auditing activities. Responsible for performing 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 of clinical staff in utilization management, care management, member assessment, and/or other teams - monitoring for compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and state and federal guidelines and requirements.

• Reports 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).

• Demonstrates professionalism in all communications.

• Adheres to departmental standards, policies, protocols.

• Maintains detailed records of auditing results.

• Assists healthcare services with developing training materials or job aids as needed to address findings in audit results.

• Meets minimum production standards related to non-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

• At least 2 years health care experience, preferably in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience.

• Strong analytical and problem-solving skills.

• 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) non-clinical review/auditing experience
• Root cause analysis
• License in social worker or other behavior health specialty
  
  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