Job Description

Job Summary

Responsible for national strategic direction and oversight over a key business segment (i.e., Medicare, Marketplace, Advanced Imaging/Central UM Services), including medical care costs and care and/or utilization management.

Job Duties

• Leads the medical program for one of Molina’s products, including the analysis of medical care cost and care and/or utilization management. Leads and manages the development of techniques to effectively correct identified and anticipated utilization problems while assuring that our members receive the care they need.
• Serves as a key leader Segment/Product medical management initiatives aimed at optimizing utilization of medical resources.
• Provides national best practice strategic direction and oversight for Segment population management (including case management, utilization management, auditing, and training)
• Creates necessary cross-functional forums and uses data analysis to identify opportunities for medical cost trend and quality improvement to positively influence member care outcomes
• Leads development and implementation of national medical policy, including recommendations for modifications to improve efficiency and effectiveness. Designs standardized protocols, develops policy, and ensures timely implementation in collaboration with Health Plan Presidents and Segment leader, as well as the enterprise Clinical Policy Committee.
• Responsible for ensuring compliance with medical policy and maintaining compliance with all federal, state, and local regulatory guidelines
• Designs standardized protocols, develops policy, and ensures timely implementation with corporate and health plan input.
• Ensures adequate training occurs from knowledgeable staff and coordinates with other departments as needed. 
• Focuses on continual refinement of operational processes by using process improvement principles (PDSA, Lean Six Sigma, etc.).
• Develops, performs, and promotes interdepartmental integration and collaboration to enhance clinical services.
• Manages and evaluates team members in the performance of various clinical management activities.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Collaborates with other functional areas that interface with the Segment including medical management, network contracting & provider relations, member services, claims management, payment integrity, pharmacy, quality, and risk adjustment.
• Acts as a critical Segment Clinical Leader for external providers, regulatory (local, state, and federal) and accrediting agencies.
• Identifies potential areas of non-compliance by overseeing audits and provides advice and guidance to operational areas regarding effective processes, and policies and procedures.
• Collaborates with internal and external business partners to provide guidance and recommendations around the development, maintenance and enhancement of programs, products, and services. Accountable for Segment readiness for internal and external audits (local, state and federal) and the administration of industry best practices.
• Ensures appropriate preparation and the successful outcome of the utilization management program compliance audits.
• Ensures Department policies, procedures and activities maintain adherence to, and are compliant with all state, federal, and delegating entity regulations and policies.
•  Performs other duties and participates in organization projects as assigned.
 

Job Qualifications

JOB REQUIREMENTS:

• Active and unrestricted medical license (MD) 
• Board Certified in an approved American Board of Medical Specialties (ABMS) Medical Specialty
• 12+ years relevant experience, including a combination of experience in clinical practice and/or managed care.
• Experience in establishing or leading the following types of national programs/initiatives using the best clinical and industry practices: Post-acute care (“SNF” Skilled Nursing Facility programs), Model of Care, Palliative Care, Diabetes Prevention, Home Health, or Prior Authorizations/Referrals
• 7+ years of leadership experience
• Demonstrated ability to make strategic decisions
• Experience in leading teams focused on quality management and utilization management
• Prior experience with process improvement activities, policy & procedure development, and operational efficiency.
• Knowledge of health care regulatory and legislative process; ability to read and interpret legislation.
• Strong analytical and research skills.
• Strong verbal and written communication skills.
• Demonstrated ability to manage multiple complex priorities, often with limited timeframes.
• Interpersonal skills; ability to interact effectively and professionally with all levels in the organization.

PREFERRED REQUIREMENTS:

• Utilization Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other healthcare or management certification, preferred.
• Board Certification (Pediatrics, Family Practice, Ob/Gyn or Internal Medicine), preferred.
 

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.