Job Summary
Provides support for Healthcare Services clinical long-term services and supports (LTSS) auditing activities. Performs risk-focused audits and analyses to identify member health and safety concerns, emerging patterns, and gaps in risk identification, mitigation, documentation, escalation, and follow-up. Contributes to an overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- Conducts retrospective, concurrent, and targeted audits of care management records, assessments, member-centered plans, risk reduction agreements, critical incidents, functional level service review assessment, residential placement activities, home and community-based services (HCBS) and care coordination, case notes, hospitalizations, workflows, reports, and other information relevant to member health and safety.
- Reviews LTSS, HCBS, care management, and utilization management activities to ensure risks are identified across the continuum of care.
- Facilitates reviews to ensure risks are identified consistently, linked to appropriate mitigation strategies, documented clearly and comprehensively, followed through timely, and escalated when unresolved or time sensitive.
- Identifies trends related to residential placement, HCBS service delivery, critical incidents, care coordination, provider performance, and other factors that may impact member health and safety.
- Uses clinical, operational, critical incident, care management, utilization management, and quality information to identify patterns, combinations of factors, outliers, and member cohorts that may signal increased vulnerability.
- Analyzes audit results and internal metrics across care management and utilization management units, departments, regions, member populations, time periods, residential settings, and other service delivery systems to identify recurring or emerging member health and safety risks.
- Validates data quality and maintains traceability of findings to source documentation.
- Reports outcomes, identifies areas of re-training for staff, and communicates findings to leadership.
- Documents findings, risk level, recommended action, accountable owner, due date, status, escalation point, and evidence needed to confirm completion.
- Conducts follow-up review to verify that required corrections or interventions occurred and evaluates whether actions improved the related operational measure, member outcome, or risk condition.
- 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), demonstrates professionalism in all communications, and adheres to departmental standards, policies, protocols.
- Maintains detailed records of auditing results.
- Assists with developing training materials or job aids as needed to address findings in audit results.
- Meets minimum production standards related to non-clinical auditing.
- May conduct staff training as needed.
- Communicates with Quality and Healthcare Services leadership regarding issues identified and works collaboratively to subsequently resolve/correct.
Required Qualifications
- At least 3 years of healthcare experience, preferably in care management, utilization management, and/or managed care, and at least 2 years of experience in LTSS, quality improvement, audit, and/or member health and safety activities, or equivalent combination of relevant education and experience.
- Registered Nurse (RN). License must be active and unrestricted in state of practice.
- Demonstrated experience working with data, reports, or audit results to identify trends, outliers, and opportunities for improvement.
- Strong analytical and problem-solving skills.
- Strong attention to detail and organizational skills.
- Ability to work in a cross-functional, professional environment.
- Ability to work on a team and independently.
- Strong verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
- Microsoft Excel proficiency, including organizing, reconciling, filtering, and analyzing data.
- In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements).
Preferred Qualifications
- Care management, utilization management, behavioral health, quality, and/or LTSS clinical review/auditing experience.
- Experience with Medicaid long-term care populations, member-centered planning, critical incidents, transitions of care, or high-risk member oversight.
- Certified Professional in Healthcare Quality (CPHQ), Certified Internal Auditor (CIA), or other related quality, audit, data, or risk certification.
- Experience with dashboards, data visualization, statistical analysis, or reporting tools.
Pay Range: $29.05 - $56.64 / HOURLY