Job Summary

Develops clinical and administrative policies and processes for the Medicare line of business to ensure CMS and other regulatory requirements are met. Coordinates policy and procedural requirements between Medical Management and Healthcare Services departments, vendors, and delegated entities 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. 

 

Job Duties

Responsible for oversight of clinical policy applicable to the Medicare population, ensuring compliance with CMS rules and regulations. Makes recommendations for enterprise standardization and adoption of clinical guidelines. Identifies potential gaps in policy and process using current working knowledge of CMS rules and requirements; proposes and implements solutions and monitors outcomes to ensure compliance. Organizes and participates in Medicare UM Committee meetings, including preparing agendas and meeting minutes, facilitating related communications, and providing policy recommendations to the Chief Medical Officer and other Medical Directors. Provides oversight of vendor clinical policy programs and collaborates with the Delegation Oversite department to ensure compliance with CMS and other regulatory requirements. Collaborates with internal teams to prepare data and documentation in response to external audit requirements; participates in external audits representing clinical teams. Develops responses to Corrective Action Plans (CAPs) and Performance Improvement Plans (PIPs) and ensures required outcomes are implemented and reported. 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. Maintains professional relationships with provider services 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/KNOWLEDGE, SKILLS & ABILITIES:

5+ years of healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, quality, compliance.  Minimum 2 years of experience working with CMS rules, regulations and guidelines, including National and Local Coverage Determinations (NCD/LCD). Experience working within applicable state, federal, and third-party regulations. Microsoft Excel proficiency

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

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

PREFERRED EDUCATION:

Master’s Degree preferred

PREFERRED EXPERIENCE:

3+ years supervisory/management experience in a managed healthcare environment.    Medicare Population experience with increasing responsibility. Experience in preparation for and participating in Medicare audits. Experience appraising evidence and synthesizing clinical policy. 3+ years of clinical nursing experience.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

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.

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