Auditor, Long-Term Services & Supports (must reside in WI)

JOB DESCRIPTION Job Summary

Provides support for Healthcare Services clinical and non-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/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 or member health and safety activities, or equivalent combination of relevant education and experience.

• 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/non-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.

#PJHS2

#LI-AC1

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $26.41 - $51.49 / HOURLY

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