Auditor, Healthcare Services (Remote in MI)

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. 


 

• 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. 


 

• 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.

• Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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.



 

• 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