Healthcare Services Auditor (RN) – Clinical Quality Performance

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