KNOWLEDGE/SKILLS/ABILITIES

Oversees an auditing team responsible monthly auditing of HCS staff.

This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals and Grievances experience and a clinical background. The candidate must have strong organization skills, proficient knowledge of MS Excel, self-driven and experience identifying areas for process enhancement. Further details to be discussed during our interview process.

This is a remote position.

Work hours: Monday- Friday: 8:00am -5:00pm.

Michigan RN license preferred.

• Functions as a hands-on supervisor, providing direction and guidance to the auditing team to ensure implementation of activities that align with Molina auditing policy and protocols

• Assists Manager with data for team member performance reviews

• Provides employee development and recognition; and assists with selection, orientation and mentoring of new staff.

• Works with the Manager to ensure adequate staffing and production levels are maintained

• 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 registered nurses and other clinical staff regarding appropriate clinical decision-making.

• Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to staff and 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..

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN) Program and an Associate's or bachelor’s degree in Nursing.

Michigan unrestricted license preferred.

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 Registered Nurse (RN) License in good standing.

• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

• 3-5 years in case management, disease management, managed care or medical or behavioral health settings.

• One year of auditing/ clinical review experience.

• More than one-year supervisory 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: $69,779 - $155,508 / ANNUAL

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