RN Auditor, Clinical Services remote based in WA

Job DescriptionThe Clinical Services Auditor performs auditing of clinical staff 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.This position will be supporting our Washington State Plan. We are seeking a candidate with a WA RN licensure and previous experience in case management within a MCO preferred, knowledge of NCQA standards for case management, and understanding of state Medicaid contracts. The Auditor should have the ability to reference/ remember rules, standards, policy procedure language and can search for the most current versions of these documents where they are housed. Proficient technology experience and experience using CCA, QNXT, Epic, PRISM, IPRO SalesForce, UMK2, and Microsoft Office and Teams programs is highly preferred. Must be able to work independently in a high-volume environment, be detail-oriented, a self-starter, and manage work time wisely. Further details to be discussed during our interview process.Remote position in WA state. Work hours: Monday-Friday: 8:00AM - 5:00PM PST WA RN licensure requiredKNOWLEDGE/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).
• Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
• Assesses clinical staff regarding appropriate 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.
• Assists in preparation for regulatory audits by performing file review and preparation.
• Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management.
• 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.

• Minimum two years UM, CM, MAT, HM, DM, and/or managed care experience.
• Proficient knowledge of Molina workflows.
• Required License, Certification, Association
• Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
• Active and unrestricted license in good standing as applicable.
• Preferred Experience
• 3-5 years of experience in case management, disease management or utilization management in managed care, medical or behavioral health settings.
• Two years of clinical auditing/review experience.