Lead, Auditor (RN) Remote

Job Description

KNOWLEDGE/SKILLS/ABILITIES

Oversees an auditing team responsible monthly auditing of HCS staff.

This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals and Grievances experience and a clinical background. The candidate must have strong organization skills, proficient knowledge of MS Excel, self-driven and experience identifying areas for process enhancement. Further details to be discussed during our interview process.

This is a remote position.

Work hours: Monday- Friday: 8:00am -5:00pm.

Michigan RN license preferred.

• Functions as a hands-on supervisor, providing direction and guidance to the auditing team to ensure implementation of activities that align with Molina auditing policy and protocols
• Assists Manager with data for team member performance reviews
  • Provides employee development and recognition; and assists with selection, orientation and mentoring of new staff.
• Works with the Manager to ensure adequate staffing and production levels are maintained
• Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
• Audits for clinical gaps in care from a medical and/or behavioral perspective to ensure member needs are being met.
• Assesses registered nurses and other clinical staff regarding appropriate clinical decision-making.
• Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to staff and 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 with all communications.
• Adheres to departmental standards, policies, protocols.
• Maintains detailed records of auditing results.
• Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
  • Meets minimum production standards
  • May conduct staff trainings as needed
• Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them..

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN) Program and an Associate's or bachelor’s degree in Nursing.

Michigan unrestricted license preferred.

Required Experience

• Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
• Proficient knowledge of Molina workflows.
• Required License, Certification, Association
• Active, unrestricted State Registered Nurse (RN) License in good standing.
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

• 3-5 years in case management, disease management, managed care or medical or behavioral health settings.
• One year of auditing/ clinical review experience.
• More than one-year supervisory experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Info

Job Identification: 2029561

Job Category: Clinical

Posting Date: 2025-01-02T18:53:40 00:00

Job Schedule: Full time