Auditor, Healthcare Services Operations Support

Job Summary

About the role

Provides support for clinical healthcare services auditing activities. Responsible for performing 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.

Responsibilities

• Performs audits of clinical staff in utilization management, care management, member assessment, and/or other teams - monitoring for compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and state and federal guidelines and requirements.
• Reports 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).
• Demonstrates professionalism in all communications.
• Adheres to departmental standards, policies, protocols.
• Maintains detailed records of auditing results.
• Affords assistance to healthcare services with developing training materials or job aids as needed to address findings in audit results.
• Mets minimum production standards related to non-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.

Requirements

• At least 2 years health care experience, preferably in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience.
• Strong analytical and problem-solving skills.
• Ability to work in a cross-functional, professional environment.
• Ability to work on a team and independently.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Qualifications

• Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) non-clinical review/auditing experience
• Root cause analysis
• Licenses in social worker or other behavior health specialty

Skills

• Strong analytical and problem-solving skills
• Excellent verbal and written communication skills
• Microsoft Office suite/applicable software program(s) proficiency

Benefits

Not specified

Pay

$24 - $46.81 / HOURLY

Schedule

Not specified