Job Description

JOB DESCRIPTION Job Summary
Provides executive level strategy and leadership to team responsible for the development and administration of state health plan operational functions, programs and services - ensuring functional operations, contractual compliance, and alignment with health plan member satisfaction, retention, quality, and financial goals.

Essential Job Duties
• Supports executive strategy development, vision and direction for designated state health plan operations function. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
• Under the leadership of the health plan president, directs and coordinates state health plan operations.
• Accountable for ensuring health plan operating metrics consistently meet and/or exceed all compliance requirements, and key performance targets and associated service level agreements (SLAs).
• Plans, organizes, staffs, and coordinates the operations of state Medicaid/Children's Health Insurance Plan (CHIP), Medicare and Marketplace health plan operations.
• Collaborates will staff and senior leadership to develop and implement improvements and oversight for non-clinical health plan operations.
• Serves as the senior plan leader and liaison for corporate operations including: claims, configuration information management, enrollment, support center operations, information technology, provider configuration management, program integrity, risk adjustment, provider resolution, provider appeals and grievances, member appeals and grievances, and other departments as required.; shared services operations that support the health plan have dotted line responsibility and accountability.
• Proactively develops, tracks, and reports to plan leadership and corporate operations performance relative to plan compliance requirements, key performance targets and/or associated SLAs.
• Quickly escalates performance issues to the plan president and plan leadership along with clear action plans to mitigate; identifies and adopts best practices from across the enterprise for health plan and corporate operations - developing strategies and tactics in partnership with corporate operations to mitigate any issues or performance levels not meeting established service levels and provides corporate oversight including the efficacy of vendor management.
• Serves as liaison with enrollment and support center operations leaders to ensure full and consistent compliance with the health plan state contract and regulatory requirements; works collaboratively with corporate business owners to mitigate risk related to enrollment processes and support center performance.
• Directs analytical activities to identify trends and potential opportunities with corporate operations functions that may impact the functionality of health plan operations.
• Directly manages the plan's benefit configuration, claim payment policies and the maintenance or modification of such, to support accurate and timely claims payments.; manages the plan's provider configuration/information activities to ensure compliance with regulatory requirements and accurate claims and encounter submissions.
• Partners to support plan encounter submissions to regulators.
• Leads efforts with local data/business analysts to audit provider contract loads and claims payments to ensure compliance with provider contract requirements.
• May directly manage the project management and process improvement teams and resources.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of quality/department-specific goals.
• Develops and sustains a high-performance team, dedicated to best in class solutions; responsible for attracting, developing and retaining top-tier talent to support strategy and long-term business objectives.

Required Qualifications
• At least 12 years of health care operations, health care administration, and/or provider services experience, or equivalent combination of relevant education and experience.
• At least 7 years of management/leadership experience.
• Deep experience with Medicare, Medicaid, and Marketplace plans.
• Experience with prompt pay laws.
• Claims-related experience.
• Demonstrated adaptability and flexibility to change, and to new ideas and approaches.
• Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders.
• Project management experience.
• Excellent verbal and written communication skills.
• Microsoft Office suite proficiency (including Excel), and applicable software programs proficiency.

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.