JOB DESCRIPTION Job Summary

Provides medical oversight and expertise in appropriateness and medical necessity of health care services provided to plan members - targeting improvements in efficiency and satisfaction for member patients and providers, in addition to meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Demonstrates and facilitates conformance to Medicare, Medicaid, National Committee for Quality Assurance (NCQA) and other regulatory requirements.
• Reviews quality referred issues, focused reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and others as directed by the chief medical officer.
• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements plan medical policies.
• Provides implementation support for quality improvement activities.
• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions if needed.
• Collaborates with contracting department in contract negotiations.
• Fosters clinical practice guideline implementation and evidence-based medical practices.
• Utilizes information technology and data analysts to produce tools to report, monitor and improve utilization management.
• Actively participates in regulatory, professional and community activities.

Required Qualifications

• At least 8 years of health care experience, including 5 years of clinical practice experience, 3 years utilization/quality program management experience, and 2 years managed care experience, or equivalent combination of relevant education and experience.
• Advanced Practice Registered Nurse (APRN) license. License must be active and unrestricted in the state of practice.
• Current clinical knowledge.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Excellent time-management and prioritization skills; ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving and critical-thinking skills.
• Ability to work in a high-pressure environment.
• Ability to maintain attendance to support required quality and quantity of work.
• Ability to maintain confidentiality and comply with health insurance portability and accountability act (HIPAA).
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
• Knowledge of applicable state, federal and third party regulations.
• Strong verbal and written communication skills.
• Microsoft Office proficiency, and ability to navigate an electronic medical record (EMR) system.

Preferred Qualifications

• Board certification (primary care preferred).
• Peer review, medical policy/procedure development, and/or provider contracting experience.
• Experience with National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data Information Set (HEDIS), Medicaid, Medicare and Pharmacy Benefit Management (PBM), Group/IPA practice, capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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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Pay Range: $117,731 - $229,576 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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