Job Description

Job Summary

Develops clinical policies 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. The Mgr, HCS Clinical Policy provides operational management and oversight to 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. This is done by closely monitoring and coordinating Molina Clinical Policies.

 

Job Duties

Responsible for oversight of clinical policy team (including operational teams, where integrated) performing one or more of the following activities:  utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.). Makes recommendation for enterprise standardization and adoption of clinical guidelines. 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  Functions as hands-on manager responsible for supervision and coordination of enterprise clinical policy to drive integrated healthcare service activities. Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff compliance and accuracy and other performance indicators. Collates and reports on Prior Authorization and Claim statistics including plan utilization, 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 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, care transition and/or disease management.  Minimum 2 years of healthcare/Medicare or health plan supervisory or managerial experience, including oversight of clinical staff. Experience working within applicable state, federal, and third-party regulations. Microsoft Excel intermediate to advanced 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. 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.