Washington – Remote RN Clinical Services Auditor

Job Overview

  • Specialty License RN
  • State License(s) WA

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.

Qualifications

Job Qualifications

Required Education
• Completion of an accredited Registered Nurse (RN) Program
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 Washington RN 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.

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