Auditor, Healthcare Services (RN)

JOB DESCRIPTION Job Summary Provides support for healthcare services clinical auditing activities. Performs 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 in utilization management, care management, member assessment, behavioral health, and/or other clinical teams, and monitors clinical staff for compliance with National Committee for Quality Assurance, Centers for Medicare and Medicaid Services (CMS), and state/federal guidelines and requirements. May also perform non-clinical system and process audits as needed.  • Audits for clinical gaps in care from a medical and/or behavioral health perspective to ensure member needs are being met.  • Assesses clinical staff regarding appropriate clinical decision-making.  • Reports monthly 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), and professionalism in all communications.  • Adheres to departmental standards, policies and protocols.  • Maintains detailed records of auditing results.  • Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results.  • Meets minimum production standards related to 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, with at least 1 year experience in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience.  • Registered Nurse (RN). License must be active and unrestricted in state of practice.  • Strong attention to detail and organizational skills.  • 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) clinical review/auditing experience. 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