Job Summary

Reporting to the Marketplace segment leader at Molina, the VP, Marketplace Clinical Operations leads a team that works with members, providers and multidisciplinary team to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum. This includes physical health and behavioral health for members with high need potential. Healthcare services 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. 

 Job Duties

Provides leadership, direction and oversight to the segment clinical teams – specifically care management and utilization management – designed to achieve best in class performance as defined by identified metrics and holds individuals accountable to achieve such measures. Leads, manages, and implements effective standards, protocols, processes, decision support systems, reporting and benchmarks that support ongoing improvements of clinical operations functions and promote quality cost effective health care for Molina members.  Ensures that the clinical models for both care and utilization management reflect applicable federal and state-specific requirements while serving the unique needs of the Marketplace population. Partners with enterprise teams to ensure that the appropriate technical systems are in place to support team success. Develops initiatives to achieve budgeted reductions in medical expenses and increases in quality scores. Offers a positive leadership role in key medical management initiatives and analytical studies aimed at optimizing utilization of medical resources and maximizing operational efficiencies.  Engages with the provider community via the health plan network teams to identify tangible opportunities for improvement of member outcomes. Oversees and ensures compliance with contractual, accreditation and regulatory requirements relative to clinical operations. Creates a culture that fosters team engagement and retention. Responsible for oversight of healthcare services related to delegation oversight monitoring. Oversees and directs the rendering of medical management decisions at all levels of the Segment that maximize benefits for our members while pursuing and supporting corporate objectives. Coordinates clinical activities with Molina corporate vendors and state plans. Coordinates the execution of audits to improve team performance.

Job Qualifications

REQUIRED EDUCATION:

Bachelor’s Degree in Healthcare, Business, or a related field

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

10 years managed care experience with management responsibility including clinical operations.  Experience working within applicable state, federal, and third-party regulations.  Operational and process improvement experience. Strong communication and teaming/interpersonal skills. Strong leadership capabilities and ability to initiate and maintain cross-team relationships.

PREFERRED EDUCATION:

Masters Degree in Business or Healthcare management (i.e. MBA, MHA, MPH).   

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

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