Auditor, Healthcare Services (RN)

Job description

JOB DESCRIPTION: Job Summary: Provides 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 H...