Remote Auditor, Clinical Services - RN preferred id-12770
About the position
The position involves performing monthly audits of clinical functions within Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and Disease Management (DM). The role focuses on ensuring compliance with various regulatory standards and preparing for regulatory audits, while also providing training and support to clinical staff based on audit findings.
Responsibilities
- Perform monthly auditing of registered nurse and other clinical functions in UM, CM, MAT, HM, and DM.
- Monitor key clinical staff for compliance with NCQA, CMS, State and Federal requirements.
- Conduct non-clinical system and process audits as needed.
- Assess clinical staff regarding appropriate decision-making.
- Report monthly outcomes and identify areas for re-training staff.
- Communicate findings to leadership and ensure adherence to Molina standards in auditing approaches.
- Assist in preparation for regulatory audits by performing file reviews and preparation.
- Participate in regulatory audits as a subject matter expert and fulfill different audit team roles as required by management.
- Maintain member/provider confidentiality in compliance with HIPAA.
- Adhere to departmental standards, policies, and protocols.
- Maintain detailed records of auditing results.
- Assist HCS training team with developing training materials or job aids based on audit findings.
- Meet minimum production standards.
- Conduct staff trainings as needed.
- Communicate with QA supervisor/manager about identified issues and collaborate to resolve them.
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Requirements
- Completion of an accredited Registered Nurse (RN) Program and an Associate's or Bachelor's degree in Nursing, or a Bachelor's or Master's degree in social science, psychology, gerontology, public health, social work, or a related field.
- Minimum two years of experience in UM, CM, MAT, HM, DM, and/or managed care.
- Proficient knowledge of Molina workflows.
- Valid driver's license with a good driving record and reliable transportation.
- Active and unrestricted license in good standing as applicable.
Nice-to-haves
- 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.
Benefits
- Competitive benefits and compensation package.
