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Job description
JOB DESCRIPTION Job Summary
Leads and supervises a multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
Oversees team performance for one or more of the following healthcare services functions: care management, utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), transition of care, behavioral health, long-term services and supports (LTSS), and/or special programs.
Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model.
Functions as a “hands‑on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery.
Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
Assists in implementing care management, utilization management, behavioral health, care transitions, LTSS and other program activities in accordance with regulatory, contract standards and accreditation compliance.
Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence.
Ensures high‑risk, complex members are adequately supported.
Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services.
Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs.
Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care.
Oversees interdisciplinary care team (ICT) meetings.
Analyzes 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, 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.
Identifies opportunities for care delivery/quality/operational/etc. process improvements.
Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals.
Local travel may be required (based upon state/contractual requirements).
Required Qualifications
At least 5 years of health care experience, including at least 2 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience.
Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
Strong customer service skills/member‑centric focus.
Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations.
Ability to prioritize and manage multiple deadlines.
Strong organizational and problem‑solving skills.
Ability to collaborate cross‑functionally within a highly matrixed organization.
Strong written and verbal communication skills.
Microsoft Office suite and applicable software program(s) proficiency.
Preferred Qualifications
Management/leadership experience.
Clinical experience.
Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice.
Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification.
Medicaid/Medicare population experience.
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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Worksite address
fort myers, FL, 33916, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.