Auditor, Clinical Services

JOB DESCRIPTION Job Summary

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. 
 

Essential Job Duties

• 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. 
 

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.

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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