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

About the role

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.

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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