Pay: $49.09 per hour
Hours: Monday-Friday 8 am-5 pm
Location: Remote in CA
Position Purpose: File Chart Review
Responsibilities:
- 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.
Requirements:
2+ years of Utilization Review Experience
2+ years of Auditing Experience
CA Licensed LVN OR RN
#INDAS
Job Type: Full-time
Pay: $49.09 per hour
Expected hours: 40 per week
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Experience:
- Utilization review: 2 years (Required)
- Auditing: 2 years (Required)
License/Certification:
Location:
Work Location: Remote