**REGISTERED NURSE Must be licensed for the state of South Carolina.
Work Schedule: EASTERN daytime business hours
KNOWLEDGE/SKILLS/ABILITIES
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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).
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Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
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Assesses clinical staff regarding appropriate decision-making.
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Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to leadership.
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Ensures auditing approaches follow a Molina standard in approach and tool use.
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Assists in preparation for regulatory audits by performing file review and preparation.
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Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management.
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Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications.
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Adheres to departmental standards, policies, protocols.
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Maintains detailed records of auditing results.
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Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
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Meets minimum production standards.
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May conduct staff trainings as needed.
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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
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Minimum two years UM (Utilization Management ) and managed care (Medicaid/ Medicare UM reviews)
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Proficient knowledge of Molina workflows.
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Required License, Certification, Association
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Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
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Active and unrestricted license in good standing as applicable
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Preferred Experience
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3-5 years of experience in case management, disease management or utilization management in managed care, medical or behavioral health settings.
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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.
#PJNurse
#LI-AC1
Pay Range: $25.08 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
