RN Auditor, Utilization Management (REMOTE) – (, South Carolina, United States)

**REGISTERED NURSE  Must be licensed for the state of South Carolina. 

Work Schedule: EASTERN daytime 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).
• 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.

JOB QUALIFICATIONS

Required Education

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

Required Experience

• Minimum two years UM (Utilization Management  ) and managed care (Medicaid/ Medicare UM reviews) 
• 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.

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.

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Pay Range: $25.08 – $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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Source: Working at Molina Healthcare