Candidates must have current CALIFORNIA licensure to be considered for this position.
Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Excellent skillset working with EMR's and Microsoft Office.
Home office with internet connectivity of high speed required. You must provide your own home office including desk and chair.
Work Schedule: Monday thru Friday 8:30AM to 5:30PM Pacific. Candidates who do not live in California must be willing to work Pacific CA hours.
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.
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.
Pay Range: $21.6 - $46.81 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
