Job Description

Provides support for clinical facility site reviews. Under the supervision of leadership, uses clinical judgement within appropriate scope to independently conduct reviews and other monitoring activities for primary care providers, specialty care providers, skilled nursing facilities, sub-acute facilities, intermediate care facilities for developmentally disabled and community-based adult services sites, and other network providers. Completes reviews in alignment with local/state/federal requirements and internal Molina policies and procedures. Leverages survey review data to develop reports, document review outcomes, and identify opportunities for ongoing program improvement. Contributes to overarching strategy to provide quality and cost-effective member care.

Job Duties

• Conducts onsite, virtual and/or desktop reviews, including but not limited to the following: Physical Accessibility Review Survey (PARS), CR5/ member grievance reviews, Healthcare Delivery Organization (HDO)/credentialing reviews, initial health appointment medical record reviews, quality grant program reviews, and Quality Assurance Performance Improvement (QAPI) reviews.
• Completes all aspects of facility site reviews using appropriate assessment tool and established regulations/policies and procedures.
• Reviews and audits provider quality programs, processes, and policies.
• Documents discussions and correspondence in facility site review (FSR) files as appropriate.
• Documents review outcomes and other details in designated database, develops reports, and ensures proper document collection throughout the review process.
• Communicates and coordinates information and findings from site visits between FSR leadership, internal and external staff and customers.
• Assists with quality interventions program documentation and updates, reports, presentations, etc.
• Represents as a Molina liaison to address provider questions and concerns.
• Collaborates directly with providers to provide education, resources and tools to assist in achieving and maintaining compliance with local, state, and federal requirements.
• Provides tools and resources to promote and facilitate access to preventive and other important health services.
• Supports the development of facility site review policies, procedures and processes.
• Identifies and supports ongoing program improvement opportunities and initiatives.
• Provides technical assistance to providers, medical groups, and internal partners to enable delivery of accessibility information to Molina members.
• Participates in PARS trainings, internal/departmental/collaborative meetings, workgroups and completes required compliance trainings to maintain necessary knowledge and skills.
• Maintains confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Collaborates with leadership to establish individual and team goals.
• Completes special assignments and projects as assigned.

Job Qualifications

REQUIRED QUALIFICATIONS:

• At least 2 years of related clinical/quality review experience, or equivalent combination of relevant education and experience.
• Active and unrestricted Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) in state of practice. This position requires same-day out-of-office travel 50- 75% of the time, depending on location. (on average the nurses are in the field 3-4 days per week)
This position may require multiple days’ out of town overnight travel 0 - 30% of the time, depending upon location.
• Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and situations.
• Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations.
• Critical thinking skills.
• Proactive, detail oriented, and organized.
• Ability to work cross-functionally across a highly matrixed organization.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

PREFERRED QUALIFICATIONS:

• Managed care experience.
• Quality improvement and/or auditing experience.
• Successful completion of PARS training and/or PARS certification.

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.