Location: San Diego,CA, USA
*****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.
Pay Range: $27.61 - $53.83 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.