***California residents preferred. 

**Out of state candidates must be licensed for CA and must be willing to support PACIFIC TIME ZONE business 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 

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.