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Utilization Management Auditor information

What is a utilization management auditor?

A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.

What are the key skills and qualifications needed to thrive as a utilization management auditor?

To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.

What are some common challenges faced by utilization management auditors and how can they be addressed?

Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.

What is the difference between Utilization Management Auditor vs Utilization Review Nurse?

AspectUtilization Management AuditorUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or CUCLicensed Registered Nurse (RN), often with additional certifications
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinics, insurance companies, often in clinical settings
Primary FocusAuditing and reviewing utilization data for compliance and cost managementAssessing patient care needs and determining appropriate services

While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.

What are popular job titles related to Utilization Management Auditor jobs in California?

For Utilization Management Auditor jobs in California, the most frequently searched job titles are:

What job categories do people searching Utilization Management Auditor jobs in California look for?

The top searched job categories for Utilization Management Auditor jobs in California are:

What cities in California are hiring for Utilization Management Auditor jobs?

Cities in California with the most Utilization Management Auditor job openings:

Utilization Management Auditor jobs near you

Auditor, Clinical Services

Molina Healthcare

Long Beach, CA

$29.05 - $56.64/hr

Full-time

Re-posted 22 days ago

Molina Healthcare rating

8.0

Company rating: 8.0 out of 10

Based on 199 frontline employees who took The Breakroom Quiz

167th of 311 rated insurance

Job description

JOB DESCRIPTION Job Summary

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

Essential Job Duties


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 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


At least 2 years health care experience, with at least 1 year experience in utilization management, care management, and/or managed care, or equivalent combination of relevant education and experience. 
Registered Nurse (RN). License must be active and restricted in state of practice. 
Strong attention to detail and organizational skills. 
Strong analytical and problem-solving skills. 
Ability to work in a cross-functional, professional environment. 
Ability to work on a team and independently. 
Excellent verbal and written communication skills. 
Microsoft Office suite/applicable software program(s) proficiency. 

Preferred Qualifications


Utilization management, care management, behavioral health and/or long-term services and supports (LTSS) clinical review/auditing experience.


#PJCorp3

#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: $29.05 - $56.64 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Employment Type: Full Time

What Molina Healthcare employees say

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Hours and flexibility

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About Molina Healthcare

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Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Long Beach, CA, US

Year founded

1980

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