The ideal candidate must live in California and some minimal travel will be required.
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) 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 clinical staff regarding appropriate clinical decision-making.
- Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings 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.
- 15% travel required.
JOB QUALIFICATIONS
Required Education
Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program and/or Associate’s or bachelor’s degree in Health 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
- Active, unrestricted State Licensed Vocational Nurse or Practical Nurse (LVN or LPN) in good standing.
- Must have valid driver’s license with good driving record and be able to drive within applicable state or locality with reliable transportation.
Preferred Experience
More than one-year managed care experience. One year of UM, CM, DM auditing experience.
Pay Range: $21.82 – $42.55 an hour*
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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.