Company Detail

Job Description

JOB DESCRIPTION

Job Summary

Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

KNOWLEDGE/SKILLS/ABILITIES

• Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.

• Provides coordination and processing of pharmacy prior authorization requests and/or appeals.

• Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.

• Assists with clerical services/tasks and other day-to-day operations as delegated.

• Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.

• Assists member and providers with initiating oral and written coverage determinations and appeals.

• Records calls accurately in call tracking system.

• Maintains specific quality and quantity standards.

JOB QUALIFICATIONS

Required Education

High School Diploma or GED equivalent

Required Experience

1-3 years of call center or customer service experience

Preferred Education

Associate degree

Preferred Experience

• 3-5 years; healthcare industry experience preferred

• National pharmacy technician certification

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.

Pay Range: $11.09 - $24.02 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.

Job Duties

• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

• Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.

• Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.

• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

• Reviews quality referred issues, focused reviews and recommends corrective actions.

• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

• Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.

• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

• Develops and implements plan medical policies.

• Provides implementation support for Quality Improvement activities.

• Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.

• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

• Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

• Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

• Doctorate Degree in Medicine

• Board Certified or eligible in a primary care specialty

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 3+ years relevant experience, including:

• 2 years previous experience as a Medical Director in a clinical practice.

• Current clinical knowledge.

• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

• Knowledge of applicable state, federal and third party regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Current state Medical (MI) license without restrictions to practice and free of sanctions from Medicaid or Medicare.

PREFERRED EDUCATION:

Master's in Business Administration, Public Health, Healthcare Administration, etc.

PREFERRED EXPERIENCE:

• Peer Review, medical policy/procedure development, provider contracting experience.

• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

• Experience in Utilization/Quality Program management

• HMO/Managed care experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Board Certification (Primary Care preferred).

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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.

Pay Range: $161,914.25 - $315,732.79 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Do you want a career where you build lasting relationships with the people you partner with? Do you want to make a difference in the lives of people with long-term health care needs? Then TMG wants to hear from you!

We're currently looking for someone with a social services or human services background to join our team. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS Program and the TMG IRIS Consultant Agency. While your office will be home-based, you will have regularly scheduled visits with IRIS participants in their home and community.

As an IRIS Consultant (IC), you will build relationships with the people you partner with and help them navigate and get the most out of the Wisconsin IRIS program - a Medicaid long-term care option for older adults and people with disabilities. You can learn more about the IRIS program on the Wisconsin Department of Health Services website here (https://dhs.wisconsin.gov/iris/index.htm) . Together, you will identify the long-term care goals of the people enrolled in IRIS, and find creative ways to achieve those goals.

ICs play an important role in helping people of various backgrounds and abilities live the lives that they choose. In fact, people constantly tell us how supportive our ICs are and what a positive impact our ICs have had on their lives! Successful candidates for this position will be compassionate, genuine, resourceful partners with an eye for high quality work, and who are excited to work side-by side with people enrolled in IRIS.

As an IC, you will connect people to the resources available in their community. You will also help them develop customized IRIS plans for achieving their goals related to employment, housing, health, safety, community membership, transportation, and lasting relationships. While you will have a routine for the work that you do, no two days are alike!

TMG wants to find the best possible candidates, so we created this Realistic Job Preview to provide you with an inside look at the position and our organization. Find out more about the IRIS Consultant position by clicking on the link (https://www.youtube.com/watch?v=2vCojx1dK3I) and then reviewing the job posting below.

TMG is committed to maintaining a diverse and inclusive workforce and prioritizes helping staff have a good work/life balance. Even though the position is remote, you'll have lots of support from your TMG team and coworkers across the organization. If this sounds like the job for you, apply today!

KNOWLEDGE/SKILLS/ABILITIES

• Required to meet in person with the IRIS participant a minimum of four times per year, with one required annual visit in the home of the participant. Because IRIS is a self-directed program, it is important for ICs to be available upon the request of the participant.

• Responsible for providing program orientation to new participants. During this time, participants will learn their rights and responsibilities as someone enrolled in the IRIS program, including verifying legal documents, completing employee paperwork and the responsible use of public dollars.

• Explore a broad view of the participant's life, including goals, important relationships, connections with the local community, interest in employment, awareness of the Self-Directed Personal Care option, and back-up support plans.

• Assist participants in identifying personal outcomes and ensure those outcomes are being met on an ongoing basis, all while staying within the participant's IRIS budget and within the requirements of the IRIS program determined by the Department of Health Services (DHS).

• Responsible for documenting all orientation and planning activities within the IRIS data system (WISITs) within 48 business hours of the visit with the participant.

• Research community resources and natural supports that will fit the individual outcomes for each participant and share that information with them as it becomes available.

• Responsible for documenting progress and changes as needed within the plan and the data system anytime a modification is requested by a participant.

• Budget Amendment or One-Time Expense paperwork may be required depending upon factors associated with the participant and their individual IRIS budget.

• Educate participants on how to read and interpret their monthly budget reports to ensure that participants operate within their budget. Being a liaison between the Fiscal Employer Agency and the IRIS Consultant Agency is also a large part of the position, which includes assisting participants with provider billing, seeking support brokers, tracking receipts, ensuring their workers are paid and mitigating areas of potential risk or conflicts of interest.

• Responsible to develop engaged and trusting relationships with participants and communicate program changes and compliance effectively.

• Responsible to maintain confidentiality and HIPPA compliance.

• Work collaboratively with other IRIS Consultant Agency staff in order to ensure a successful implementation of participants' plans.

• Attend in-person monthly team meetings with other ICs and their supervisor. In addition, weekly IC and IRIS Consultant Supervisor phone check-ins may occur, along with other duties as assigned.

JOB QUALIFICATIONS

Required Education

Bachelor's degree in a social work, psychology, human services, counseling, nursing, special education, or a closely related field (or four years of commensurate experience if no degree).

Required Experience

• 1+ year of direct experience related to the delivery of social services to the target groups (individuals with intellectual or physical disabilities and older adults).

• Ability to work independently, with minimal supervision and be self-motivated.

• Knowledge of Long-Term Care programs and familiarity with principles of self-determination.

• Excellent problem-solving skills, critical thinking skills and strong basic math skills.

• Excellent time management and prioritization skills to focus on multiple projects simultaneously and adapt to change.

• Ability to develop and maintain professional relationships and work through situations without taking it personally.

• Comfortable working within a variety of settings and adjust style as needed; to work with a diverse population, various personalities, and personal situations.

• Resourceful and have knowledge of community resources while being proactive and detail oriented.

• Ability to use a variety of technology including but not limited to, Outlook, Skype, Teams, PowerPoint, Excel, Word, online portals and databases.

Required License, Certification, Association

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

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.

Pay Range: $18.04 - $35.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

We are seeking a RN (Registered Nurse) Case Manager for Washoe County, NEVADA. Qualified candidate must currently live in Washoe County. Must be licensed as a RN for the state of NV. Nevada is not a compact state at this time. Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important.

This is a remote based position and you can work from home. TRAVEL in the field to do member visits in the county will be required. Mileage will be reimbursed.

Schedule: Monday thru Friday 8:00AM to 5:00PM / 1 hour lunch break.

Further details to be discussed with our hiring team in the interview process.

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• 25- 40% local travel required.

• RNs provide consultation, recommendations and education as appropriate to non-RN case managers.

• RNs are assigned cases with members who have complex medical conditions and medication regimens

• RNs conduct medication reconciliation when needed.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.

Required Experience

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

Preferred License, Certification, Association

Active, unrestricted Certified Case Manager (CCM)

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.

#PJHS

#LI-AC1

Pay Range: $23.76 - $51.49 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

We are seeking a RN (Registered Nurse) Case Manager for Washoe County, NEVADA. Qualified candidate must currently live in Washoe County. Must be licensed as a RN for the state of NV. Nevada is not a compact state at this time. Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important.

This is a remote based position and you can work from home. TRAVEL in the field to do member visits in the county will be required. Mileage will be reimbursed.

Schedule: Monday thru Friday 8:00AM to 5:00PM / 1 hour lunch break.

Further details to be discussed with our hiring team in the interview process.

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• 25- 40% local travel required.

• RNs provide consultation, recommendations and education as appropriate to non-RN case managers.

• RNs are assigned cases with members who have complex medical conditions and medication regimens

• RNs conduct medication reconciliation when needed.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.

Required Experience

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

Preferred License, Certification, Association

Active, unrestricted Certified Case Manager (CCM)

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.

#PJHS

#LI-AC1

Pay Range: $23.76 - $51.49 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Responsible for analysis of financial reports, trend, and opportunities. Includes evaluation of and recommendations relating to business opportunities, investments, financial regulations, and similar financial projects or programs. Duties include gathering, interpreting, and evaluating financial information; generating forecasts and analyzes trends in sales, finance and other areas of business; Creating financial models for future business planning decisions in areas such as new product development, new marketing strategies, etc.

KNOWLEDGE/SKILLS/ABILITIES

• Forecasts and monitors economic benefits of Molina investments in infrastructure and operations (enhancements in operating efficiency and effectiveness).

• Allocates limited resources among different investments in infrastructure and operations by ranking based upon economic benefit.

• Analyzes capital equipment purchases. Performs lease vs. buy analyses.

• Assists the IT Technology department with financial modeling, budgeting, benchmarking analysis and variance analysis as needed.

• Develops policies and procedures to support all Finance activities.

JOB QUALIFICATIONS

Required Education

Bachelor's Degree

Required Experience

3-4 Years

Preferred Education

MBA

Preferred Experience

• 5-6 Years

• Preferred License, Certification, Association

• CPA

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.

#PJCorp

#LI-AC1

Pay Range: $54,373.27 - $117,808.76 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily/weekly production goals and maintaining a high level of confidentiality for provider information.

Job Duties

- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.

- Communicates with health care providers to clarify questions and request any missing information.

- Updates credentialing software systems with required information.

- Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.

- Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.

- Completes data corrections in the credentialing database necessary for processing of recredentialing applications.

- Reviews claims payment systems to determine provider status, as necessary.

- Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.

- Reviews and processes daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.

- Reviews and processes daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.

- Reviews and processes daily NPDB Continuous Query reports and takes appropriate action when new reports are found.

JOB QUALIFICATIONS

Required Education:

High School Diploma or GED.

Required Experience/Knowledge Skills & Abilities

- Experience in a production or administrative role requiring self-direction and critical thinking.

- Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.

- Experience with professional written and verbal communication.

Preferred Experience:

Experience in the health care industry

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

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

KNOWLEDGE/SKILLS/ABILITIES

• Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.

• Provides coordination and processing of pharmacy prior authorization requests and/or appeals.

• Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.

• Assists with clerical services/tasks and other day-to-day operations as delegated.

• Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.

• Assists member and providers with initiating oral and written coverage determinations and appeals.

• Records calls accurately in call tracking system.

• Maintains specific quality and quantity standards.

JOB QUALIFICATIONS

Required Education

High School Diploma or GED equivalent

Required Experience

1-3 years of call center or customer service experience

Preferred Education

Associate degree

Preferred Experience

• 3-5 years; healthcare industry experience preferred

• National pharmacy technician certification

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.

Pay Range: $11.09 - $24.02 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

*Remote and must live in Michigan*

Job Description

Job Summary

Molina Health Plan Network Provider Relations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Relations staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.

Job Duties

This role serves as the primary point of contact between Molina Health plan and the Plan's Complex Provider Community that services Molina members, including but not limited to Value Based Payment and other Alternative Payment Method contracts. It is an external-facing, field-based position requiring an in-depth knowledge of provider relations and contracting subject matter expertise to successfully engage complex providers, including senior leaders and physicians, to ensure provider satisfaction, education on key Molina initiatives, and improved coordination and partnership.

- Under general supervision, works directly with the Plan's external complex providers to educate, advocate and engage as valuable partners, ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service.

- Resolves complex provider issues that may cross departmental lines including Contracting, Finance, Quality, Operations, and involve Senior Leadership.

- Responsible for Provider Satisfaction survey results.

- Develops and deploys strategic network planning tools to drive Provider Relations and Contracting Strategy across the enterprise.

- Facilitates strategic planning and documentation of network management standards and processes. Effectiveness is tied to financial and quality indicators.

- Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practices sharing across the organization.

- MCST matrix team environmental support including, but not limited to: New Markets Provider/Contract Support Services, PCRP & CSST resolution support, and National Contract Management support services.

- Serves as a subject matter expert for other departments.

- Conducts regular provider site visits within assigned region/service area. Determines own daily or weekly schedule, as needed to meet or exceed the Plan's monthly site visit goals. A key responsibility of the Representative during these visits is to proactively engage with the provider and staff to determine, for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members.

- Provides on-the-spot training and education as needed, which may include counseling providers diplomatically, while retaining a positive working relationship.

- Independently troubleshoots problems as they arise, making an assessment when escalation to a Senior Representative, Supervisor, or another Molina department is needed. Takes initiative in preventing and resolving issues between the provider and the Plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters.

- Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians. For example, such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding.

- Independently delivers training and presentations to assigned providers and their staff, answering questions that come up on behalf of the Health plan. May also deliver training and presentations to larger groups, such as leaders and management of provider offices (including large multispecialty groups or health systems, executive level decision makers, Association meetings, and JOC's).

- Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives. Examples of such initiatives include: administrative cost effectiveness, member satisfaction - CAHPS, regulatory-related, Molina Quality programs, and taking advantage of electronic solutions (EDI, EFT, EMR, Provider Portal, Provider Website, etc.).

- Trains other Provider Relations Representatives as appropriate.

- Role requires 60%+ same-day or overnight travel. (Extent of same-day or overnight travel will depend on the specific Health Plan and its service area.)

Job Qualifications

REQUIRED EDUCATION :

Bachelor's Degree in a healthcare related field or an equivalent combination of education and experience.

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES :

- 4-6 years provider contract network relations and management experience in a managed healthcare setting.

- Working experience servicing complex providers with various managed healthcare provider compensation methodologies, including but not limited to: fee-for service, value-based contracts, capitation and various forms of risk, ASO, etc.

PREFERRED EDUCATION :

Master's Degree in Health or Business related field

PREFERRED EXPERIENCE :

- 5 years experience in managed healthcare administration.

- Specific experience in provider services, operations, and/or contract negotiations in a Medicare and Medicaid managed healthcare setting, ideally with different provider types (e.g., physician, groups and hospitals).

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.

Pay Range: $54,373.27 - $117,808.76 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily/weekly production goals and maintaining a high level of confidentiality for provider information.

Job Duties

- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.

- Communicates with health care providers to clarify questions and request any missing information.

- Updates credentialing software systems with required information.

- Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.

- Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.

- Completes data corrections in the credentialing database necessary for processing of recredentialing applications.

- Reviews claims payment systems to determine provider status, as necessary.

- Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.

- Reviews and processes daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.

- Reviews and processes daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.

- Reviews and processes daily NPDB Continuous Query reports and takes appropriate action when new reports are found.

JOB QUALIFICATIONS

Required Education:

High School Diploma or GED.

Required Experience/Knowledge Skills & Abilities

- Experience in a production or administrative role requiring self-direction and critical thinking.

- Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.

- Experience with professional written and verbal communication.

Preferred Experience:

Experience in the health care industry

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

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Provides telephone, clerical, and data entry support for the Care Review team.

• Provides computer entries of authorization request/provider inquiries, such as eligibility and benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information regarding admissions and discharges, and billing codes.

• Responds to requests for authorization of services submitted via phone, fax, and mail according to Molina operational timeframes.

• Contacts physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.

Job Qualifications

Required Education

HS Diploma or GED

Required Experience

1-3 years' experience in an administrative support role in healthcare.

Preferred Education

Associate degree

Preferred Experience

3+ years' experience in an administrative support role in healthcare, Medical Assistant 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.

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

KNOWLEDGE/SKILLS/ABILITIES

• Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.

• Provides coordination and processing of pharmacy prior authorization requests and/or appeals.

• Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.

• Assists with clerical services/tasks and other day-to-day operations as delegated.

• Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.

• Assists member and providers with initiating oral and written coverage determinations and appeals.

• Records calls accurately in call tracking system.

• Maintains specific quality and quantity standards.

JOB QUALIFICATIONS

Required Education

High School Diploma or GED equivalent

Required Experience

1-3 years of call center or customer service experience

Preferred Education

Associate degree

Preferred Experience

• 3-5 years; healthcare industry experience preferred

• National pharmacy technician certification

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.

Pay Range: $11.09 - $24.02 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

We are looking for a supervisor that must reside within the state of South Carolina. The Supervisor will manage a team of Case Managers that will support the South Carolina Severe Mental Illness Medicaid population.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

Oversees an integrated Care Management team responsible for case management, community connectors, health management, and/or transition of care activities to assist Molina Healthcare members with their healthcare needs. Care Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Molina members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner.

• Functions as a hands-on supervisor, providing direction and guidance to the care management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.

• Manages staff caseloads and assigns cases appropriately regarding complexity of medical or psychosocial needs and case manager experience (RN, LSW, other allied fields).

• Oversees the staff use of the electronic case management documentation system in compliance with standard Molina processes, standard documentation styles, and HIPAA. Arranges training as needed.

• Manages, coaches and evaluates the performance of team members; provides employee development and recognition; and assists with selection, orientation and mentoring of new staff.

• Promotes multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina members. Oversees and/or participates in Interdisciplinary Care Team meetings.

• Works with the Manager to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.

• Audits case management assessments and care plan development for completeness and timeliness according to state requirements.

• Monitors onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions.

• May monitor the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.

JOB QUALIFICATIONS

Required Education

• Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license.

• OR Bachelor's or master's degree in gerontology, public health, or social work with related case management experience.

Required Experience

3 or more years in case management, disease management, managed care or medical or behavioral health settings.

Required License, Certification, Association

If licensed, license must be active, unrestricted and in good standing.

Preferred Education

Bachelor's or master's degree in Nursing,

Preferred Experience

More than five years Case Management experience. Medicaid/Medicare Population experience with increasing responsibility.

Preferred License, Certification, Association

Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

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.

Pay Range: $59,810.6 - $129,589.63 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

• Conducts telephonic, face-to-face or home visits as required.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Maintains ongoing member case load for regular outreach and management.

• Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

• May implement specific Molina wellness programs i.e. asthma and depression disease management.

• Facilitates interdisciplinary care team meetings and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

• Collaborates with RN case managers/supervisors as needed or required

• Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

• Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

KNOWLEDGE/SKILLS/ABILITIES

• Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.

• Provides coordination and processing of pharmacy prior authorization requests and/or appeals.

• Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.

• Assists with clerical services/tasks and other day-to-day operations as delegated.

• Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.

• Assists member and providers with initiating oral and written coverage determinations and appeals.

• Records calls accurately in call tracking system.

• Maintains specific quality and quantity standards.

JOB QUALIFICATIONS

Required Education

High School Diploma or GED equivalent

Required Experience

1-3 years of call center or customer service experience

Preferred Education

Associate degree

Preferred Experience

• 3-5 years; healthcare industry experience preferred

• National pharmacy technician certification

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.

Pay Range: $11.09 - $24.02 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily/weekly production goals and maintaining a high level of confidentiality for provider information.

Job Duties

- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.

- Communicates with health care providers to clarify questions and request any missing information.

- Updates credentialing software systems with required information.

- Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.

- Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.

- Completes data corrections in the credentialing database necessary for processing of recredentialing applications.

- Reviews claims payment systems to determine provider status, as necessary.

- Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.

- Reviews and processes daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.

- Reviews and processes daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.

- Reviews and processes daily NPDB Continuous Query reports and takes appropriate action when new reports are found.

JOB QUALIFICATIONS

Required Education:

High School Diploma or GED.

Required Experience/Knowledge Skills & Abilities

- Experience in a production or administrative role requiring self-direction and critical thinking.

- Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.

- Experience with professional written and verbal communication.

Preferred Experience:

Experience in the health care industry

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

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Provides telephone, clerical, and data entry support for the Care Review team.

• Provides computer entries of authorization request/provider inquiries, such as eligibility and benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information regarding admissions and discharges, and billing codes.

• Responds to requests for authorization of services submitted via phone, fax, and mail according to Molina operational timeframes.

• Contacts physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.

Job Qualifications

Required Education

HS Diploma or GED

Required Experience

1-3 years' experience in an administrative support role in healthcare.

Preferred Education

Associate degree

Preferred Experience

3+ years' experience in an administrative support role in healthcare, Medical Assistant 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.

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

KNOWLEDGE/SKILLS/ABILITIES

• Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.

• Provides coordination and processing of pharmacy prior authorization requests and/or appeals.

• Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.

• Assists with clerical services/tasks and other day-to-day operations as delegated.

• Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.

• Assists member and providers with initiating oral and written coverage determinations and appeals.

• Records calls accurately in call tracking system.

• Maintains specific quality and quantity standards.

JOB QUALIFICATIONS

Required Education

High School Diploma or GED equivalent

Required Experience

1-3 years of call center or customer service experience

Preferred Education

Associate degree

Preferred Experience

• 3-5 years; healthcare industry experience preferred

• National pharmacy technician certification

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.

Pay Range: $11.09 - $24.02 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily/weekly production goals and maintaining a high level of confidentiality for provider information.

Job Duties

- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.

- Communicates with health care providers to clarify questions and request any missing information.

- Updates credentialing software systems with required information.

- Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.

- Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.

- Completes data corrections in the credentialing database necessary for processing of recredentialing applications.

- Reviews claims payment systems to determine provider status, as necessary.

- Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.

- Reviews and processes daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.

- Reviews and processes daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.

- Reviews and processes daily NPDB Continuous Query reports and takes appropriate action when new reports are found.

JOB QUALIFICATIONS

Required Education:

High School Diploma or GED.

Required Experience/Knowledge Skills & Abilities

- Experience in a production or administrative role requiring self-direction and critical thinking.

- Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.

- Experience with professional written and verbal communication.

Preferred Experience:

Experience in the health care industry

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

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare

Job Description

JOB DESCRIPTION

Job Summary

Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.

Job Duties

• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

• Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.

• Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.

• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

• Reviews quality referred issues, focused reviews and recommends corrective actions.

• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

• Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.

• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

• Develops and implements plan medical policies.

• Provides implementation support for Quality Improvement activities.

• Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.

• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

• Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

• Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

• Doctorate Degree in Medicine

• Board Certified or eligible in a primary care specialty

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 3+ years relevant experience, including:

• 2 years previous experience as a Medical Director in a clinical practice.

• Current clinical knowledge.

• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

• Knowledge of applicable state, federal and third party regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Current state Medical (MI) license without restrictions to practice and free of sanctions from Medicaid or Medicare.

PREFERRED EDUCATION:

Master's in Business Administration, Public Health, Healthcare Administration, etc.

PREFERRED EXPERIENCE:

• Peer Review, medical policy/procedure development, provider contracting experience.

• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

• Experience in Utilization/Quality Program management

• HMO/Managed care experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Board Certification (Primary Care preferred).

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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.

Pay Range: $161,914.25 - $315,732.79 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Detail

• Company:
  Molina Healthcare