Registered Nurse

JOB DESCRIPTION

Opportunity in Southern California for an experienced Managed Care Leader to join our health plan in California. Candidates must have a minimum of 7 years of healthcare experience, 3 of those should be with a Managed Care Organization focusing on Care Management. Leadership experience of 2 – 3 years, also within an MCO, must show a clear increase in responsibility, including a proven ability to lead teams, drive performance, and support member-centered care initiatives.

Strong leadership, collaboration, and operational management skills are essential to successfully advance care delivery goals and improve member outcomes.

Job Summary

Leads and manages 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…