Company Detail

Job Description

* We are looking for candidate who can work in PST hours. ***

JOB DESCRIPTION Job Summary Designs and implements processes and solutions associated with a wide variety of data sets used for data/text mining, analysis, modeling, and predicting to enable informed business decisions. Gains insight into key business problems and deliverables by applying statistical analysis techniques to examine structured and unstructured data from multiple disparate sources. Collaborates across departments and with customers to define requirements and understand business problems. Uses advanced mathematical, statistical, querying, and reporting methods to develop solutions. Develops information tools, algorithms, dashboards, and queries to monitor and improve business performance. Creates solutions from initial concept to fully tested production, and communicates results to a broad range of audiences. Effectively uses current and emerging technologies. KNOWLEDGE/SKILLS/ABILITIES

• Extracts and compiles various sources of information and large data sets from various systems to identify and analyze outliers.

• Sets up process for monitoring, tracking, and trending department data.

• Prepares any state mandated reports and analysis.

• Works with internal, external and enterprise clients as needed to research, develop, and document new standard reports or processes.

• Implements and uses the analytics software and systems to support the departments goals.

• Must have advanced level working experience with MS Excel for data analysis, data validation and reporting.

• Must have experience working in a healthcare environment.

• Must be able to understand claims process and configuration.

• Act as a tech support to claims teams.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

1-3 years

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

3-5 years

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: $67,724.8 - $97,362.61 / 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

Provides new and existing members with the best possible service in relation to billing inquiries, service requests, suggestions, and complaints. Resolves member inquiries and complaints fairly and effectively. Provides product and service information to members and identifies opportunities to maintain and increase member relationships. Recommends and implements programs to support member needs.

KNOWLEDGE/SKILLS/ABILITIES

• Performs member outreach calls in states supported by Molina Healthcare to enforce member retention

• Answers incoming calls regarding Medicaid members in PEND status and those having Re-determination renewal dates.

• Helps members complete necessary paperwork related to either Medicaid eligibility renewal process.

• Assists Medicaid Members in contacting their social worker regarding eligibility issues and follow-up with members to ensure follow through, if allowed by the member's respective state.

• Accurately and timely documents member retention contacts in appropriate database.

JOB QUALIFICATIONS

Required Education

HS Diploma

Required Experience

1-3 years

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.

Preferred Education

Associate's Degree

Preferred Experience

3-5 years

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.

#PJHPO

#LI-AC1

Pay Range: $16.5 - $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

Molina Healthcare of Florida is hiring for several Claims Examiners.

These positions are remote; however, all candidates must reside in the state of Florida .

Those with Health Insurance call center experience are encouraged to apply. This is an entry level position where you have the opportunity for growth & advancement.

As a Claims Examiner, you will be responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensure that claims are settled in a timely fashion and in accordance with cost control standards.

KNOWLEDGE/SKILLS/ABILITIES

• Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.

• Manages a caseload of claims. Procures all medical records and statements that support the claim.

• Makes recommendations for further investigation or resolution.

• Reduces defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.

• Supports all department initiatives in improving overall efficiency.

• Meets department quality and production standards.

• Other duties as assigned.

JOB QUALIFICATIONS

Required Education : HS Diploma or GED

Preferred Education : Associate degree or equivalent combination of education and experience

Required Experience : 1-3 years of claims knowledge

Preferred Experience : 3-5 years of claims knowledge

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance

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

*This position is remote and employee must reside in Florida*

Job Summary

Analyzes complex business problems and claims issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.

KNOWLEDGE/SKILLS/ABILITIES

• Provides analytical, problem solving foundation within claims including: definition and documentation, specifications.

• Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.

• Reviews, researches, analyzes and evaluates all data relating to specific area of expertise. Begins process of becoming subject matter expert.

• Conducts analysis and uses analytical skills to identify root cause and assist with problem management as it relates to state requirements.

• Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery and cost savings regulations are met

• Prepares high level user documentation and training materials as needed.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

• 3-5 Years of business analysis

• 4+ years managed care experience

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

• 1-3 years formal training in Business Analysis and/or Systems Analysis

• 1+ years claims background

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: $19.64 - $42.55 / 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

Candidates For This Position Must Reside In/Near the Erie County Area

Are you passionate about serving others? Do you have established relationships within the community?

Come join our growing Community Engagement team at Molina Healthcare !

Community Outreach and Engagement is more than just participating in events- at Molina, we focus on making an impact on people's lives!

This role involves working with a wide variety of community partners to grow Molina's membership and improve the health and well-being of the Community. Our Specialists work collaboratively with our sales team and across Molina and with each other's regions. You would be responsible for managing events and community relationships in Erie and surrounding counties. You will be in the field engaging with CBO's (Community Based Organizations) 50% or more of the time (Molina reimburses mileage).

This position offers great flexibility and allows for you to manage your territory and schedule to meet business needs. Molina's leadership team leads with empowering you to do what you love best by helping others.

Bilingual (Spanish) Highly Desired!

*Candidates for this position must live in or near the Erie County Area*

KNOWLEDGE/SKILLS/ABILITIES

• Responsible for achieving established goals improving Molina's enrollment growth objectives encompassing Medicaid programs. Works collaboratively with key departments across the enterprise to improve overall choice rates and assignment percentages.

• Under limited supervision, responsible for carrying out enrollment events and achieving assigned membership growth targets through a combination of direct and indirect marketing activities, with the primary responsibility of improving the plan's overall -choice- rate. Works collaboratively with other key departments to increase the Medicaid assignment percentage for Molina.

• Works closely with other team members and management to develop/maintain/deepen relationships with key business leaders, community-based organizations (CBOs) and providers, ensuring all efforts are directed towards building membership for Medicaid and related programs. Effectively moves relationships through the -enrollment- pipeline.

• Responsible for achieving monthly, quarterly, and annual enrollment goals, and growth and choice targets, as established by management.

• Schedules, coordinates & participates in enrollment events, encourages key partners to participate, and assists where feasible.

• Works cohesively with Provider Services to ensure providers within assigned territory are aware of Molina products and services. Establishes simple referral processes for providers and CBOs to refer clients who may be eligible for other Molina products.

• Viewed as a -subject matter expert- (SME) by community and influencers on the health care delivery system and wellness topics.

• Delivers presentations, attends meetings and distributes educational materials to both members and potential members.

• Assists with all incoming calls and assist perspective members or members with health access related questions.

• Identify partnerships with key sponsorship opportunities and provide justification to determine Molina's participation.

• Identify and promote Molina's programs out in the community and creates opportunities for employees to participate.

• Responsible for managing their own daily schedule in alignment with department goals and initiatives as assigned by regions.

• Key in the development of SMART goals and provide input on department priorities.

JOB QUALIFICATIONS

Required Education: Bachelor's Degree or equivalent, job-related experience.

Preferred Education: Bachelor's Degree in Marketing or related discipline.

Required Experience:

• Min. 3 years of related experience (e.g., marketing, business development, community engagement, healthcare industry).

• Demonstrated exceptional networking and negotiations skills.

• Demonstrated strong public speaking and presentations skills.

• Demonstrated ability to work in a fast-paced, team-oriented environment with little supervision.

• Must be able to attend public events in outdoor venues in all weather conditions.

• Must be able to sit and stand for long periods.

• Must be able to drive up to 3 hours to attend events. Must be able to lift 30 pounds.

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.

Preferred Experience:

• Solid understanding of Health Care Markets, primarily Medicaid.

• Previous healthcare marketing, enrollment and/or grassroots/community outreach experience a plus.

• 5 years of outreach experience serving low-income populations.

• 3 - 5 years project management experience, preferably in a health care or outreach setting.

• Experience presenting to influencer and low-income audiences.

• Experience in sales or marketing techniques.

• Fluency in a second language highly desirable.

Preferred License, Certification, Association:

• Active Life & Health Insurance

• Market Place Certified

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.

Key Words: health care, insurance, health insurance, Medicaid, Medicare, health coach, community health advisor, family advocate, health educator, liaison, promoter, outreach worker, peer counselor, patient navigator, health interpreter and public health aide, community lead, community advocate, nonprofit, non-profit, social worker, case worker, housing counselor, human service worker, Navigator, Assistor, Connecter, Promotora, Marketing, Sales, Growth, New York, MCO, Managed Care, ACA, FQHC, Behavioral Health, CHW, Community Health Worker, Equity, DPBH, HMO, SDOH

Pay Range: $16.23 - $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

Molina Healthcare of Florida is hiring for several Sr. Claims Examiners.

These roles remote, however candidates must reside in Florida.

Ideal candidates will have experience with claims adjudication, claims edits, payout evaluation, front end claims processing, and Excel. QNXT experience a plus!

KNOWLEDGE/SKILLS/ABILITIES

• Responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

• Meets and consistently maintains production standards for Claims Adjudication.

• Supports all department initiatives in improving overall efficiency.

• Identifies and recommends solutions for error issues as it relates to pre-payment of claims.

• Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.

• Monitors the medical treatment of claimants. Keeps meticulous notes and records for each claim.

• Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.

• Meets department quality and production standards.

• Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.

• Other duties as assigned.

JOB QUALIFICATIONS

Required Education : High School or GED

Preferred Education : Bachelor's Degree or equivalent combination of education and experience

Required Experience : 3-5 years claims processing required

Preferred Experience : 5-7 years claims processing 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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance, Front End Claims, Claims Processing, Excel

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

• Serves as a community based member advocate and resource, using knowledge of the community and resources available to engage and assist vulnerable members in managing their healthcare needs.

• Collaborates with and supports the Healthcare Services team by providing non-clinical paraprofessional duties in the field, to include meeting with members in their homes, nursing homes, shelters, or doctor's offices, etc.

• Empowers members by helping them navigate and maximize their health plan benefits.

• Assistance may include: scheduling appointments with providers; arranging transportation for healthcare visits; getting prescriptions filled; and following up with members on missed appointments.

• Assists members in accessing social services such as community-based resources for housing, food, employment, etc.

• Provides outreach to locate and/or provide support for disconnected members with special needs.

• Conducts research with available data to locate members Molina Healthcare has been unable to contact (e.g., reviewing internal databases, contacting member providers or caregivers, or travel to last known address or community resource locations such as homeless shelters, etc.)

• Participates in ongoing or project-based activities that may require extensive member outreach (telephonically and/or face-to-face).

• Guides members to maintain Medicaid eligibility and with other financial resources as appropriate.

• 50-80% local travel may be required. Reliable transportation required.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

HS Diploma/GED

REQUIRED EXPERIENCE:

- Minimum 1 year experience working with underserved or special needs populations, with varied health, economic and educational circumstances.

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.

- For Ohio, Florida, and California only -- Active and unrestricted Community Health Worker (CHW) Certification.

PREFERRED EDUCATION:

Associate's Degree in a health care related field (e.g., nutrition, counseling, social work).

PREFERRED EXPERIENCE:

- Bilingual based on community need.

- Familiarity with healthcare systems a plus.

- Knowledge of community-specific culture.

- Experience with or knowledge of health care basics, community resources, social services, and/or health education.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

- Current Community Health Worker (CHW) Certification preferred (for states other than Ohio, Florida and California, where it is required).

- Active and unrestricted Medical Assistant Certification

STATE SPECIFIC REQUIREMENTS: OHIO

- MHO Care Guide serves as a single point of contact for care coordination when there is no CCE, OhioRISE Plan, and/or CME involvement and short term care coordination needs are identified MHO Care Guide Plus serves as a single point of contact at Molina for care coordination when there is CCE, OhioRISE Plan, and/or CME involvement and short term care coordination needs are identified.

- Assures completion of a health risk assessment, assisting members to remediate immediate and acute gaps in care and access. Assist members with filing grievances and appeals.

- Connects members to CCEs, the OhioRISE Plan,or Molina Care Management if the members needs indicate a higher level of coordination. Provide information to members related to Molina requirements , services and benefits .

- Knowledge of internal MCO processes and procedures related to Care Guide responsibilities required

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.

#PJHPO

Pay Range: $14.76 - $31.97 / 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

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery.

KNOWLEDGE/SKILLS/ABILITIES

• Reviews post pay claims with corresponding medical records to determine accuracy of claims payments.

• Review of applicable policies, CPT guidelines, and provider contracts.

• Devise clinical summary post review.

• Communicate and participate in meetings related to cases.

• Critical thinking, problem solving and analytical skills.

• Ability to prioritize and manage multiple tasks.

• Proven ability to work in a team setting.

• Ability to analyze data to identify FWA Trends

• Excellent oral and written communication skills and presentation skills.

JOB QUALIFICATIONS

Required Education

High School Diploma / GED (or higher)

Required Experience

• 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location

• Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

Required License, Certification, Association

Certified Coder (CPC, CCS, and/or CPMA)

Preferred Education

Bachelor's degree (or higher)

Preferred Experience

• 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

• A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

• Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

• Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings.

Preferred License, Certification, Association

• AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

• Certified Fraud Examiner and/or AHFI professional designations 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: $19.64 - $42.55 / 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

*This position is remote and employee must reside in Florida*

Job Summary

Analyzes complex business problems and claims issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.

KNOWLEDGE/SKILLS/ABILITIES

• Provides analytical, problem solving foundation within claims including: definition and documentation, specifications.

• Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.

• Reviews, researches, analyzes and evaluates all data relating to specific area of expertise. Begins process of becoming subject matter expert.

• Conducts analysis and uses analytical skills to identify root cause and assist with problem management as it relates to state requirements.

• Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery and cost savings regulations are met

• Prepares high level user documentation and training materials as needed.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

• 3-5 Years of business analysis

• 4+ years managed care experience

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

• 1-3 years formal training in Business Analysis and/or Systems Analysis

• 1+ years claims background

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: $19.64 - $42.55 / 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

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. COMPACT / Multi state RN LICENSURE IS PREFERABLE to support multiple states.

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. Home office with private desk area, and high speed internet connectivity required.

Work Schedule: 4 days week/ 10 hours per day some weekends and holidays are required.

PACIFIC HOURS start time at 7:00AM / 8:00AM or 9:00AM.

Candidates who do not live in Pacific , must work Pacific hours.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home.

Further Details to be discussed during our 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

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.

• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.

• Processes requests within required timelines.

• Refers appropriate prior authorization requests to Medical Directors.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

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

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: $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

POPULATION / PUBLIC HEALTH REGISTERED NURSE CASE MANAGER

We are looking for a Case Manager who must reside and be able to drive within CLARK COUNTY NEVADA

Must have experience with chronic conditions and public health, communicable diseases, and engagement with community partners in the Clark County NV area.

Case Manager will work in remote and field setting our Medicaid Population. 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. Excellent skillset working with EMR's and Microsoft Office.

TRAVEL WILL BE REQUIRED (up to 40% 2 - 3 days a week ) in the field to do member visits in the surrounding areas. Travel will be within a 2 hour radius. A clean DMV driving record, proof of auto insurance, and reliable transportation is required.

Home office with internet connectivity of high speed required. You must provide your own home office including desk and chair.

Schedule: Monday thru Friday 8:00AM to 5:00PM.

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.

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

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. COMPACT / Multi state RN LICENSURE IS PREFERABLE to support multiple states.

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. Home office with private desk area, and high speed internet connectivity required.

Work Schedule: 4 days week/ 10 hours per day some weekends and holidays are required.

PACIFIC HOURS start time at 7:00AM / 8:00AM or 9:00AM.

Candidates who do not live in Pacific , must work Pacific hours.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home.

Further Details to be discussed during our 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

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.

• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.

• Processes requests within required timelines.

• Refers appropriate prior authorization requests to Medical Directors.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

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

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: $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

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

• Provide non-clinical operational support for Waiver coordination.

• Facilitate communication between Waiver coordinators and the state Program Support Unit.

• Responsible for receiving the initial State referrals for waiver services and working with the Long-Term Services & Supports (LTSS) Coordinator to schedule the initial assessment.

• Monitor status for initial assessment, reassessment, and transition assessments for members.

• Interface with the State agency that determines eligibility and the LTSS Coordinator to process and obtain approval of Waiver services.

• Monitors transition process of Nursing Facility members in custodial beds to return to the community for 'Money Follows the Person' program.

• Initiates referral for Medicare and Waiver process if member is not already Medicare or waiver established.

• Tracks referrals and case documents via designated state systems.

• Track activities occurring within the transitional, assessment and authorization processes, using internal systems and designated state systems, and report results to coordinators, supervisors, and the State agency.

• Ensure Medicaid and Waiver eligibility have been requested and received from state partners before transition or services are initiated.

• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

• Attend internal meetings and regularly scheduled calls as assigned.

• Other administrative functions as needed.

JOB QUALIFICATIONS

Required Education

HS Diploma or GED

Required Experience

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

• Experience demonstrating ability to handle multiple work tasks, prioritize tasks, and excellent problem solving.

• Experience demonstrating strong communication skills.

Preferred Education

Associate degree

Preferred Experience

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

• 2 years Long Term Care experience preferred and/or Managed Care experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer

(EOE) M/F/D/V

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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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 accurate and timely implementation and maintenance of critical information on claims databases. Maintains critical information on claims databases. Synchronizes data among operational and claims systems and application of business rules as they apply to each database. Validate data to be housed on databases and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.

KNOWLEDGE/SKILLS/ABILITIES

• Analyze and interpret data to determine appropriate configuration changes.

• Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.

• Handles coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.

• Apply previous experience and knowledge to research and resolve claim/encounter issues, pended claims and update system(s) as necessary.

• Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of user community.

• Must be able to do deep dive root cause analysis and research on claims

JOB QUALIFICATIONS

Required Education

Associate degree or equivalent combination of education and experience

Required Experience

2-5 years

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

5-7 years

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: $49,430.25 - $107,098.87 / 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

Serves as claims subject matter expert. Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied. Manages and leads major claims projects of considerable complexity and volume that may be initiated through provider inquiries or complaints, legal requests, or identified internally by Molina. Identifies the root cause of processing errors through research and analysis, coordinates and engages with appropriate departments, develops and tracks remediation plans, and monitors claims reprocessing through resolution. Interprets and presents in-depth analysis of findings and results to leadership and respective operations teams. Responsible for ensuring the projects are completed accurately and timely.

Job Duties

• Uses analytical skills to conducts research and analysis for issues, requests, and inquiries of high priority claims projects

• Assists with reducing re-work by identifying and remediating claims processing issues

• Locate and interpret regulatory and contractual requirements

• Tailors existing reports or available data to meet the needs of the claims project

• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors

• Applies claims processing and technical knowledge to appropriately define a path for short/long term systematic or operational fixes

• Helps to improve overall claims performance to ensure claims are processed accurately and timely

• Identifies claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance

• Works closely with external departments to define claims requirements

• Recommends updates to Claims SOP's and Job Aid's to increase the quality and efficiency of claims processing

• Fields claims questions from Molina Operations teams

• Interprets, communicates, and presents, clear in-depth analysis of claims research results, root cause analysis, remediation plans and fixes, overall progress, and status of impacted claims

• Provides excellent customer services to our internal operations teams concerning claims projects

• Appropriately convey information and tailor communication based on the targeted audience

• Provides sufficient claims information to our internal operations teams that must communicate externally to provider or members

• Able to work in a project team setting while also able to complete tasks individually within the provided timeline or as needed, accelerated timeline to minimize provider/member impacts and/or maintain compliance

• Manages work assignments and prioritization appropriately

• Other duties as assigned.

Job Qualifications

REQUIRED EDUCATION:

Associate's degree or equivalent combination of education and experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 1-3 years claims analysis experience

• 5+ years medical claims processing experience across multiple states, markets, and claim types

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas

• Knowledge and experience using Excel

PREFERRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

• 1-3 years claims analysis

• 6+ years medical claims processing experience

• Project management

• Expert in Excel and PowerPoint

PHYSICAL DEMANDS:

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.

#PJCorp

#LI-AC1

Pay Range: $17.85 - $38.69 / 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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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

Serves as claims subject matter expert. Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied. Manages and leads major claims projects of considerable complexity and volume that may be initiated through provider inquiries or complaints, legal requests, or identified internally by Molina. Identifies the root cause of processing errors through research and analysis, coordinates and engages with appropriate departments, develops and tracks remediation plans, and monitors claims reprocessing through resolution. Interprets and presents in-depth analysis of findings and results to leadership and respective operations teams. Responsible for ensuring the projects are completed accurately and timely.

Job Duties

• Uses analytical skills to conducts research and analysis for issues, requests, and inquiries of high priority claims projects

• Assists with reducing re-work by identifying and remediating claims processing issues

• Locate and interpret regulatory and contractual requirements

• Tailors existing reports or available data to meet the needs of the claims project

• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors

• Applies claims processing and technical knowledge to appropriately define a path for short/long term systematic or operational fixes

• Helps to improve overall claims performance to ensure claims are processed accurately and timely

• Identifies claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance

• Works closely with external departments to define claims requirements

• Recommends updates to Claims SOP's and Job Aid's to increase the quality and efficiency of claims processing

• Fields claims questions from Molina Operations teams

• Interprets, communicates, and presents, clear in-depth analysis of claims research results, root cause analysis, remediation plans and fixes, overall progress, and status of impacted claims

• Provides excellent customer services to our internal operations teams concerning claims projects

• Appropriately convey information and tailor communication based on the targeted audience

• Provides sufficient claims information to our internal operations teams that must communicate externally to provider or members

• Able to work in a project team setting while also able to complete tasks individually within the provided timeline or as needed, accelerated timeline to minimize provider/member impacts and/or maintain compliance

• Manages work assignments and prioritization appropriately

• Other duties as assigned.

Job Qualifications

REQUIRED EDUCATION:

Associate's degree or equivalent combination of education and experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 1-3 years claims analysis experience

• 5+ years medical claims processing experience across multiple states, markets, and claim types

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas

• Knowledge and experience using Excel

PREFERRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

• 1-3 years claims analysis

• 6+ years medical claims processing experience

• Project management

• Expert in Excel and PowerPoint

PHYSICAL DEMANDS:

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.

#PJCorp

#LI-AC1

Pay Range: $17.85 - $38.69 / 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

INPATIENT REVIEW : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated.

Further details to be discussed during our 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

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Molina Care Model.

• Adheres to UM policies and procedures.

• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

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.

State Specific Requirements:

CA Qualifications: Licensed within the state of CALIFORNIA

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

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: $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 accurate and timely implementation and maintenance of critical information on claims databases. Maintains critical information on claims databases. Synchronizes data among operational and claims systems and application of business rules as they apply to each database. Validate data to be housed on databases and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.

KNOWLEDGE/SKILLS/ABILITIES

• Analyze and interpret data to determine appropriate configuration changes.

• Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.

• Handles coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.

• Apply previous experience and knowledge to research and resolve claim/encounter issues, pended claims and update system(s) as necessary.

• Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of user community.

• Must be able to do deep dive root cause analysis and research on claims

JOB QUALIFICATIONS

Required Education

Associate degree or equivalent combination of education and experience

Required Experience

2-5 years

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

5-7 years

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: $49,430.25 - $107,098.87 / 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

Responsible for accurate and timely implementation and maintenance of critical information on claims databases. Maintains critical information on claims databases. Synchronizes data among operational and claims systems and application of business rules as they apply to each database. Validate data to be housed on databases and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.

KNOWLEDGE/SKILLS/ABILITIES

• Analyze and interpret data to determine appropriate configuration changes.

• Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.

• Handles coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.

• Apply previous experience and knowledge to research and resolve claim/encounter issues, pended claims and update system(s) as necessary.

• Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of user community.

• Must be able to do deep dive root cause analysis and research on claims

JOB QUALIFICATIONS

Required Education

Associate degree or equivalent combination of education and experience

Required Experience

2-5 years

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

5-7 years

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: $49,430.25 - $107,098.87 / 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

Serves as claims subject matter expert. Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied. Manages and leads major claims projects of considerable complexity and volume that may be initiated through provider inquiries or complaints, legal requests, or identified internally by Molina. Identifies the root cause of processing errors through research and analysis, coordinates and engages with appropriate departments, develops and tracks remediation plans, and monitors claims reprocessing through resolution. Interprets and presents in-depth analysis of findings and results to leadership and respective operations teams. Responsible for ensuring the projects are completed accurately and timely.

Job Duties

• Uses analytical skills to conducts research and analysis for issues, requests, and inquiries of high priority claims projects

• Assists with reducing re-work by identifying and remediating claims processing issues

• Locate and interpret regulatory and contractual requirements

• Tailors existing reports or available data to meet the needs of the claims project

• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors

• Applies claims processing and technical knowledge to appropriately define a path for short/long term systematic or operational fixes

• Helps to improve overall claims performance to ensure claims are processed accurately and timely

• Identifies claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance

• Works closely with external departments to define claims requirements

• Recommends updates to Claims SOP's and Job Aid's to increase the quality and efficiency of claims processing

• Fields claims questions from Molina Operations teams

• Interprets, communicates, and presents, clear in-depth analysis of claims research results, root cause analysis, remediation plans and fixes, overall progress, and status of impacted claims

• Provides excellent customer services to our internal operations teams concerning claims projects

• Appropriately convey information and tailor communication based on the targeted audience

• Provides sufficient claims information to our internal operations teams that must communicate externally to provider or members

• Able to work in a project team setting while also able to complete tasks individually within the provided timeline or as needed, accelerated timeline to minimize provider/member impacts and/or maintain compliance

• Manages work assignments and prioritization appropriately

• Other duties as assigned.

Job Qualifications

REQUIRED EDUCATION:

Associate's degree or equivalent combination of education and experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 1-3 years claims analysis experience

• 5+ years medical claims processing experience across multiple states, markets, and claim types

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas

• Knowledge and experience using Excel

PREFERRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

• 1-3 years claims analysis

• 6+ years medical claims processing experience

• Project management

• Expert in Excel and PowerPoint

PHYSICAL DEMANDS:

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.

#PJCorp

#LI-AC1

Pay Range: $17.85 - $38.69 / HOURLY

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

Job Detail

• Company:
  Molina Healthcare