Healthcare Services Auditor (RN) - Clinical Quality Performance

JOB DESCRIPTION Job Summary:

Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements, accreditation standards and organizational performance standards - ensuring quality compliance and desired member outcomes and effective clinical operations. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Conducts audits, identify gaps in performance, and collaborates with clinical and operational leaders to strengthen processes, support corrective actions, and advance overall clinical quality performance.
• Monitor Key Performance Indicators (KPIs) and quality metrics to assess clinical performance and identify trends or areas for improvement.
• Tracks performance against audit thresholds and escalates risk or patterns of non-compliance to leadership.
• Support readiness for accreditation surveys and regulatory audits through documentation validation and process review.
• Prepares accurate and timely audit reports summarizing outcomes, findings and recommended corrective actions.
• 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/organizational 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

• At least 2 years health care experience, with at least 1 year experience in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and restricted in state of practice.
• Strong attention to detail and organizational skills.
• 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.

Preferred Qualifications

• Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience. KPI Performance Oversight Experience is a plus.

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

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.