Auditor, Clinical Services
Job Description
KNOWLEDGE/SKILLS/ABILITIES
? Performs 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).
? Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
? Assesses clinical staff regarding appropriate 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.
? Assists in preparation for regulatory audits by performing file review and preparation.
? Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management.
? Maintains member/provider confidentiality in compliance with the Health Insurance Portability and... Accountability Act (HIPAA) and professionalism with all communications.
? Adheres to departmental standards, policies, protocols.
? Maintains detailed records of auditing results.
? Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
? Meets minimum production standards.
? May conduct staff trainings as needed.
? Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them.
JOB QUALIFICATIONS
Required Education
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.
Required Experience
? Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
? Proficient knowledge of Molina workflows.
? Required License, Certification, Association
? Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
? Active and unrestricted license in good standing as applicable.
? Preferred Experience
? 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.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Similar Remote Jobs
Auditor, Clinical Services
Posted on: 21-08-2024 00:00
Customer Service Associate
Posted on: 21-08-2024 00:00
Remote Pharmacy Technician
Posted on: 21-08-2024 00:00
YOUTUBE CONTENT CREATOR
Posted on: 21-08-2024 00:00
Business Development Representative
Posted on: 21-08-2024 00:00
Call Center Agent
Posted on: 21-08-2024 00:00
Chat Support Supervisor
Posted on: 21-08-2024 00:00
Remote Administrative Assistant
Posted on: 21-08-2024 00:00
Amazon Customer Service
Posted on: 21-08-2024 00:00
Part-Time Remote Bookkeeper
Posted on: 21-08-2024 00:00
(Entry Level/No Experience) Disney Data Entry Jobs
Posted on: 04-02-2025 19:19
Principal Operations Strategy ? TPRM Learning Strategy
Posted on: 20-11-2024 13:46
Web Chat Officer - Work from home
Posted on: 05-09-2024 00:00
Remote Sales Representative - Training Provided/Work from Home
Posted on: 26-11-2024 06:18
American Airlines Customer Support Representative (Work From Home)
Posted on: 19-09-2024 00:00
Pharmacy Tech Liaison - Specialty - Remote - FT Days
Posted on: 31-01-2025 10:02
Pharmacy Technician, Pool
Posted on: 18-09-2024 00:00
Remote Chat Support Specialist | Join a Leading Public Relations Firm | $25 - $30/hr
Posted on: 22-11-2024 05:35
French-English - Chat and Email Customer Service Representative - Remote
Posted on: 16-01-2025 19:17
CVS Customer Service Representative Remote Jobs - Position Available
Posted on: 17-09-2024 00:00