Mgr, Healthcare Services (Appeals & Grievances)

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 The Manager, Healthcare Services provides operational management and oversight of integrated Healthcare Services (HCS) teams responsible for providing Molina Healthcare members with the right care at the right place at the right time and assisting them to achieve optimal clinical, financial, and quality of life outcomes. • Responsible for clinical teams (including operational teams, where integrated) performing one or more of the following activities: care review/utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), case management, transition of care, health management and/or member assessment. • Typically, through one or more direct report supervisors, facilitates integrated, proactive HCS management, ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina Clinical Model. • Manages and evaluates team member performance; provides coaching, counseling, employee development, and recognition; ensures ongoing, appropriate staff training; and has responsibility for the selection, orientation and mentoring of new staff. • Performs and promotes interdepartmental/ multidisciplinary integration and collaboration to enhance the continuity of care including Behavioral Health and Long-Term Services & Supports for Molina members. Oversees Interdisciplinary Care Team meetings. • Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities. • 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. • Ensures completion of 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, internal and external customers, and state agencies as appropriate, while identifying opportunities for improvement. 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 Nursing, Gerontology, Public Health, Social Work, or related field. Required Experience • 5+ years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition and/or disease management. • Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff. • Experience working within applicable state, federal, and third-party regulations. Required License, Certification, Association • If licensed, 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. Preferred Education Master's Degree preferred. Preferred Experience • 3+ years supervisory/management experience in a managed healthcare environment. • Medicaid/Medicare Population experience with increasing responsibility. • 3+ years of clinical nursing experience. Preferred License, Certification, Association Any of the following: 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: $77,969 - $171,058 / ANNUAL • Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Apply Job!