Job DescriptionJOB DESCRIPTIONProvides executive level strategy and leadership for teams responsible for optimization of clinical operations across the enterprise. Develops and implements processes to ensure healthcare services functions including utilization management/care management/etc. and clinical vendors provide services in alignment with state, federal, regulatory and Molina quality and compliance standards. Partners with executive leadership team to provide cohesive direction towards company goals. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties• Supports executive strategy development, vision and direction for enterprise clinical operations. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
• Leads, manages and implements effective standards, protocols, processes, decision support systems, reporting and benchmarks that support ongoing improvements of clinical operations functions.
• Develops initiatives to achieve budgeted reductions in medical expenses and increases in quality scores.
• Demonstrates positive leadership role in key clinical management initiatives and analytical studies aimed at optimizing utilization of clinical resources and maximizing operational efficiencies.
• Engages with provider community via 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.
• Responsible for oversight of healthcare services related to delegation oversight monitoring.
• Oversees and directs the rendering of clinical decisions at all levels of the health plan that maximize benefits for members while pursuing and supporting enterprise objectives.
• Coordinates clinical activities with enterprise vendors and state health plans.
• Coordinates the results of audits to improve team performance.
• Assists in the development of product-specific policies.
• Collaborates with contracting/network to standardize contracts for quality and utilization.
Required Qualifications• At least 12 years of managed care experience, including progressive clinical operations experience in a highly matrixed organization, or equivalent combination of relevant education and experience.
• At least 7 years of health care management/leadership experience.
• 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 operational and process improvement experience.
• Strong, visible leadership capabilities, and ability to initiate and maintain cross-team relationships.
• Understanding of the managed care industry and market conditions.
• Strong interpersonal skills.
• Strong analytical and problem-solving skills.
• Strong organizational and time-management skills.
• Ability to work in a cross-functional, highly matrixed environment.
• Experience working within applicable state, federal, and third-party regulations.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency - Excel, PowerPoint.
Preferred Qualifications• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care or management certification.
- Experience with Power BI or Tableau dashboards.
- Expertise with Medicare Duals plans.
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.
