Molina Healthcare Inc.

Compensation

Full Description

JOB DESCRIPTION Job Summary: Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements, accreditation standards and organizational performance standards - ensuring quality compliance and desired member outcomes and effective clinical operations. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Conducts audits, identify gaps in performance, and collaborates with clinical and operational leaders to strengthen processes, support corrective actions, and advance overall clinical quality performance. • Monitor Key Performance Indicators (KPIs) and quality metrics to assess clinical performance and identify trends or areas for improvement. • Tracks performance against audit thresholds and escalates risk or patterns of non-compliance to leadership. • Support readiness for accreditation surveys and regulatory audits through documentation validation and process review. • Prepares accurate and timely audit reports summarizing outcomes, findings and recommended corrective actions. • 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/organizational 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 restricted 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. KPI Performance Oversight Experience is a plus. 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 Pay Range: $29.05 - $67.97 / HOURLY • Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.