Directpr Healthcare Services Utilization Management /Operations

Molina Healthcare   •  

North Charleston, SC

Industry: Healthcare

  •  

8 - 10 years

Posted 55 days ago

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS 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.


Knowledge/Skills/Abilities

• Directs and oversees one of the following key Healthcare Services functions: case management/disease management/care transitions; utilization management; long-term supports and services; or nurse advice line.

• Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care review and management.

• Develops, performs and promotes interdepartmental integration and collaboration to enhance clinical services.

• Collaborates with and keeps the AVP or VP of Healthcare Services informed of operational issues, staffing, resources, system and program needs and presents solution action plan for issues.

• Facilitates and participates in committees, task forces, work groups and multidisciplinary teams as needed to promote standardized Molina enterprise wide approach to Care Management programs.

• Ensures monthly auditing is occurring with appropriate follow-up.

• Engaged in clinical training activities and outcomes.

• Develops and mentors HCS managers and supervisors.

Job Qualifications


Required Education

Bachelor's Degree in Healthcare-related field (equivalent combination of education, experience and/or Nursing license will be considered in lieu of Bachelor's Degree).

Required Experience

• 7+ years managed healthcare experience with line management responsibility including clinical operations.

• Experience working within applicable state, federal, and third party regulations.

Required License, Certification, Association

If licensed, license must be active, unrestricted and in good standing.

Preferred Education

Master's Degree in Business, Healthcare, Social Work or related field.

Preferred Experience

• 10+ years managed care experience.

• Operational and process improvement experience.

Preferred License, Certification, Association

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