San Antonio, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
San Antonio, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
El Paso, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
El Paso, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Austin, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Austin, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Houston, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Houston, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Corpus Christi, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
Corpus Christi, TX · Remote
$29.05 - $56.64/hr
Essential Job Duties • Performs audits in utilization management, care management, member ... auditing approaches follow a Molina standard in approach and tool use. • Maintains member ...
New
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
San Antonio, TX · On-site
Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.
Abilene, TX · On-site
$26.25 - $30/hr
... of disease pathophysiology and drug utilization Knowledge of MS-DRG classification and ... time management and assignment completion Ability to work in a virtual setting under minimal ...
Abilene, TX · On-site
$26.25 - $30/hr
... of disease pathophysiology and drug utilization Knowledge of MS-DRG classification and ... time management and assignment completion Ability to work in a virtual setting under minimal ...
The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...
Quick apply
The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...
The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...
Quick apply
The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...
Waller, TX · On-site
... management during and at the completion of examinations, reporting asset utilization and audit ... Auditors (IIA) and the American Institute of Certified Public Accountants (AICPA). • Ability to ...
Waller, TX · On-site
... management during and at the completion of examinations, reporting asset utilization and audit ... Auditors (IIA) and the American Institute of Certified Public Accountants (AICPA). • Ability to ...
San Antonio, TX · Remote
$23.50 - $26.75/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
San Antonio, TX · Remote
$23.50 - $26.75/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
San Antonio, TX · On-site
$25.10 - $40.25/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
San Antonio, TX · On-site
$25.10 - $40.25/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
San Antonio, TX · Remote
$25.10 - $40.25/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
San Antonio, TX · Remote
$25.10 - $40.25/hr
Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:
Time Management: Works efficiently and manages duties to ensure that tasks are completed with ... Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost ...
Time Management: Works efficiently and manages duties to ensure that tasks are completed with ... Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost ...
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
Bellaire, TX · On-site
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
Bellaire, TX · On-site
This process includes clinical judgment, utilization review, application of product benefits ... managed care and fraud and abuse, and verification of medical necessity utilizing nationally ...
| Aspect | Utilization Management Auditor | Utilization Review Nurse |
|---|---|---|
| Credentials | Typically requires a nursing license, certifications like CCM or CUC | Licensed Registered Nurse (RN), often with additional certifications |
| Work Environment | Office-based, insurance companies, healthcare organizations | Hospital, clinics, insurance companies, often in clinical settings |
| Primary Focus | Auditing and reviewing utilization data for compliance and cost management | Assessing 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.
San Antonio, TX • Remote
$29.05 - $56.64/hr
Full-time
This job post has expired today. Applications are no longer accepted.
8.0
Based on 197 frontline employees who took The Breakroom Quiz
163rd of 301 rated insurance
JOB DESCRIPTION
Summary of highly qualified candidates:
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 unrestricted 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.
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.
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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.
Health care and social assistance
10,000+ Employees
Long Beach, CA, US
1980
