Job Description

JOB DESCRIPTION Job Summary

Leads and manages team responsible for non-clinical and clinical audits of operations, investigations and risk assessment activities for long-term services and supports (LTSS) Healthcare Services functions; applies internal audit theory and practice to evaluate operating effectiveness and makes recommendations for training enhancements and process improvements with a primary focus on member health and safety, proactive risk identification, mitigation, follow-up, and evaluation of intervention effectiveness. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Oversees LTSS audit team responsible for audits related to member health and safety, including residential placements, home and community-based services (HCBS), member-centered planning, critical incidents, utilization management, and care management delivery and support operations.
• Establishes and maintains a risk-focused audit program that evaluates LTSS service delivery using member-level and aggregate clinical, operational, critical incident, and care management information to identify emerging or recurring health and safety risks.
• Defines risk-based audit priorities, sampling approaches, measures, thresholds, review cadence, and escalation criteria in collaboration with Quality, Care Management, Utilization Management, Member Health and Safety, and other applicable functions.
• Directs audits of risk identification, mitigation, documentation, member involvement, follow-up, escalation, and monitoring of intervention effectiveness.
• Ensures audit findings distinguish isolated corrections from recurring process, workflow, knowledge, technology, staffing, or system-level risks.
• Oversees aggregation and analysis of findings across care management and utilization management units, departments, regions, member cohorts, and risk indicators to identify patterns not visible through review of a single record, incident, or data source.
• Develops and maintains reporting, dashboards, and trend analyses related to member health and safety, including residential placement activity, HCBS services, critical incidents, risk mitigation efforts, and corrective actions across departments.
• Translates audit results, trend analyses, and member health and safety concerns into actionable recommendations and works with operational leaders to monitor implementation and effectiveness of corrective and preventive actions.
• Presents risk audit findings, member health and safety risk trends, LTSS-related findings, residential placement concerns, HCBS performance issues, emerging risks, and corrective action status to operational leaders, executive leadership, and other internal stakeholders. Reporting to include: the identified concern and/or trend, affected population or process, severity, accountable owner(s), required action, due date, status, escalation point, and evidence of completion, and facilitates discussion regarding priorities, mitigation strategies, escalation needs, resource requirements, and next steps.
• Contributes to ongoing, dynamic operational workflow improvements - appropriately escalating observations and any trending concerns with a focus on continual improvement and optimal member outcomes, as well as overall health plan performance.
• Monitors corrective and preventive actions and evaluates whether completed actions improved the related operational measure, member outcome, risk condition, or recurrence pattern.
• Maintains professional relationships with internal and external customers, while identifying opportunities for improvement.
• Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA), and professionalism in all communications.
• Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance the continuity of care and quality of Molina services provided.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
• Functions as hands-on leader responsible for supervision and coordination of daily activities.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of department-specific goals.

Required Qualifications

• At least 7 years of healthcare experience, including experience in care management, utilization management, behavioral health, and/or managed care operations - preferably in an auditing capacity, and at least 3 years of experience in LTSS, quality improvement, and/or member health and safety oversight, or equivalent combination of relevant education and experience.
• At least 1 year of healthcare management/leadership experience.
• Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Experience developing or managing risk-based audit, monitoring, or quality review programs and translating findings into corrective or preventive action.
• Demonstrated ability to analyze data from multiple sources, identify patterns and outliers, and communicate actionable risk findings to operational and executive leaders.
• Strong analytics and problem-solving abilities.
• Strong organizational and time-management skills.
• Ability to multi-task and meet project deadlines.
• Strong attention to detail.
• Ability to build relationships and collaborate cross-functionally.
• Ability to demonstrate a high level of confidentiality.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
• In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements).

Preferred Qualifications

• Managed care operations and/or clinical experience.
• Care management, utilization management, behavioral health, and/or LTSS clinical review/auditing experience.
• Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM), Certified Internal Auditor (CIA), or other related quality, audit, clinical, or risk certification.
• Experience with Medicaid long-term care populations, member-centered planning, critical incidents, transitions of care, or high-risk member oversight.
• Experience with dashboards, data visualization, statistical analysis, or reporting tools used to identify and monitor trends.

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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