Healthcare Services Auditor (RN) (New York)

Job Description

JOB DESCRIPTION Job SummaryProvides 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

Preferred Qualifications

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

Pay Range : $29.05 - $67.97 / HOURLY