JOB DESCRIPTION
Job Summary
My Choice Wisconsin with 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 Access and Monitoring team responsible for prior authorizations, inpatient/outpatient medical necessity/utilization review, and/or other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time.
Functions as a hands-on supervisor, coordinating and monitoring clinical and non-clinical team activities to facilitate integrated, proactive utilization management, ensuring compliance with regulatory and accrediting standards.
Manages and evaluates team members in the performance of various utilization management activities; provides coaching, counseling, employee development, and recognition; and assists with selection, orientation and mentoring of new staff.
Performs and promotes interdepartmental integration and collaboration to enhance the continuity of care including Behavioral Health and Long-Term Care for Molina members.
Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
Collates and reports on Care Access and Monitoring statistics including plan utilization, staff productivity, cost effective utilization of services, management of targeted member population, and triage activities.
Completes staff quality audit reviews. Evaluates services provided and outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and guidelines.
Maintains professional relationships with provider community and internal and external customers while identifying opportunities for improvement.
Assists with coordinating and facilitating weekly Inpatient and/or Outpatient UR team meetings including developing agendas, preparing needed materials, and documentation.
Participates in MetaStar and MDV audits as needed. This may include assisting UR Manager with gathering Policy and Procedure documents and validating data files against internal documentation captured and processed in MIDAS
Assists with caseload coverage, as needed, not to exceed 20 hours per week of authorization processing, both IP and OP queues.
Responds to member/provider inquiries regarding health plan coverage and benefits.
Collaborates with care management staff regarding complex cases assisting with resolving complex/escalated Prior Authorization issues as necessary.
Shares facilitation time of Home/Vehicle Modification committee meetings, including discussion of request with IDT and program leadership, completing committee documentation in Midas, providing resources of available providers for modifications and drafting potential notice of action language for IDT to utilize.
Applies knowledge of Medicare and Medicaid regulations.
JOB QUALIFICATIONS
Required Education
Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.
Required Experience
3+ years clinical nursing experience.
2+ years utilization management experience.
Experience demonstrating leadership skills.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) 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 or Master's Degree in Nursing, Health Care Administration, Public Health or related field.
Preferred Experience
5 years clinical practice with managed care, hospital nursing or utilization management experience.
3+ years supervisory experience in a managed healthcare environment.
Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.
Pay Range: $66,456 - $129,590*
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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.
