Remote Auditor, Clinical Services - RN preferred
About the position 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. 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.