Healthcare Services Auditor (RN) - Clinical Quality Performance

JOB DESCRIPTION Job Summary :

Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements, accreditation standards and organizational performance standards - ensuring quality compliance and desired member outcomes and effective clinical operations. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Conducts audits, identify gaps in performance, and collaborates with clinical and operational leaders to strengthen processes, support corrective actions, and advance overall clinical quality performance.
• Monitor Key Performance Indicators (KPIs) and quality metrics to assess clinical performance and identify trends or areas for improvement.
• Tracks performance against audit thresholds and escalates risk or patterns of non-compliance to leadership.
• Support readiness for accreditation surveys and regulatory audits through documentation validation and process review.
• Prepares accurate and timely audit reports summarizing outcomes, findings and recommended corrective actions.
• Performs audits in utilization management, care management, member assessment, behavioral health, and / or other clinical teams, and monitors clinical staff for compliance with National Committee for Quality Assurance, Centers for Medicare and Medicaid Services (CMS), and state / federal / organizational guidelines and requirements. May also perform non-clinical system and process audits as needed.
• Audits for clinical gaps in care from a medical and / or behavioral health 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 to 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 in all communications.
• Adheres to departmental standards, policies and protocols.
• Maintains detailed records of auditing results.
• Assists healthcare services training team with developing training materials or job aids as needed to address findings in audit results.
• Meets minimum production standards related to clinical auditing.
• May conduct staff trainings as needed.
• Communicates with quality and / or healthcare services leadership regarding issues identified, and works collaboratively to subsequently resolve / correct.

Required Qualifications

Preferred Qualifications

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 : $29.05 - $67.97 / HOURLY