What are the responsibilities and job description for the RN Auditor, Clinical Services - Utilization Management position at Molina Healthcare Group?
Job Description
For this position we are seeking a (RN) Registered Nurse who lives in OHIO or KENTUCY and must be licensed for the state they reside
Clinical Auditor RN will support our Ohio Health Plan, the role will require auditing charts of OH Health Plan care review clinicians (UM) and providing feedback and corrections to ensure the health plan stays compliant
We are looking for someone with strong clinical auditing skills with preference on supporting the Medicaid population, Inpatient Services, and/or Behavioral Heatlh
This is a remote position, but you must reside within 150 miles of the Columbus OH (3000 Corporate Exchange Drive Columbus OH 43231) - you will be required to attend 2 to 4 meetings a year at the local office
Home office with internet connectivity of high speed required.
Work Schedule Monday – Friday 8 AM to 5 PM EST
KNOWLEDGE/SKILLS/ABILITIES
- 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).
- Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
- Assesses clinical staff regarding appropriate 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.
- Assists in preparation for regulatory audits by performing file review and preparation.
- Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management.
- 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 Associate's or bachelor’s degree in Nursing OR Bachelor's or master’s degree in social science, psychology, gerontology, public health, social work, or related field.
Required Experience
- Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
- Proficient knowledge of Molina workflows.
- Required License, Certification, Association
- Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
- Active and unrestricted license in good standing as applicable.
- Preferred Experience
- 3-5 years of experience in case management, disease management or utilization management in managed care, medical or behavioral health settings.
- Two years of clinical auditing/review 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: 2029571
Job Category: Clinical
Posting Date: 2025-01-22T15:09:45 00:00
Job Schedule: Full time
