Manager, Healthcare Services ( Prior Authorizations )

Molina Healthcare Bothell , WA 98021

Posted 4 months ago

Job Description:

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

The Manager, Healthcare Services provides operational management and oversight of integrated Healthcare Services (HCS) teams responsible for providing Molina Healthcare members with the right care at the right place at the right time and assisting them to achieve optimal clinical, financial, and quality of life outcomes.

  • Responsible for clinical teams (including operational teams, where integrated) performing one or more of the following activities: care review/utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), case management, transition of care, health management and/or member assessment.

  • Typically through one or more direct report supervisors, facilitates integrated, proactive HCS management, ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina Clinical Model.

  • Manages and evaluates team member performance; provides coaching, counseling, employee development, and recognition; ensures ongoing, appropriate staff training; and has responsibility for the selection, orientation and mentoring of new staff.

  • Performs and promotes interdepartmental/ multidisciplinary integration and collaboration to enhance the continuity of care including Behavioral Health and Long Term Services & Supports for Molina members. Oversees Interdisciplinary Care Team meetings.

  • Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities.

  • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.

  • Collates 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 and 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 and internal and external customers while identifying opportunities for improvement.Job QualificationsRequired Education

Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license.

OR

Bachelor's or Master's Degree in Nursing, Gerontology, Public Health, Social Work or related field.

Required Experience

  • 5 years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition and/or disease management.

  • Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff.

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

Required License, Certification, Association

License must be active, unrestricted and in good standing in the State of Washington.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education

Master's Degree preferred

Preferred Experience

  • 3 years supervisory/management experience in a managed healthcare environment.

  • Medicaid/Medicare Population experience with increasing responsibility.

  • 3 years of clinical nursing experience.

Preferred License, Certification, Association

Any of the following:

Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.


upload resume icon
See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Lead IT Business Partner Connected Care & Healthcare Informatics
New!

Philips

Posted Today

VIEW JOBS 1/17/2019 12:00:00 AM 2019-04-17T00:00 Job TitleLead IT Business Partner - Connected Care & Healthcare Informatics Job Description The Lead IT BP for Connected Care and Healthcare Informatics (CCHI) is end-responsible for strategic IT partnering and relationship management across the relevant Business/Function Portfolio. They engage at the SVP, EVP, VP and Executive/Cluster levels of our organization. You will be the primary focal point for IT towards the Business/Function at the senior levels of the organization. In doing so, they provide direct support to the IT Key Account Managers (CIO and Head of Business Engagement for IT) across topics such as IT/Business strategy and road mapping and crafting IT Demands to support business needs. In addition to leading and developing a team of IT BPs and IT Business Engagement Management resources, you are also responsible for the hands-on strategic partnering towards a specific Business Cluster or Function. The main purpose of the role of Lead IT Business Partner CCHI is to assure that solutions provided by IT enable the business and business processes, decision-making for decision-making, or connect employees, customers, suppliers and shareholders with easy to use, available, reliable, serviceable, compliant, responsive and cost effective IT solutions and services for the CCHI cluster, today and in the future. Responsibilities: * Own the definition and evolution of IT strategy and delivery of roadmaps aligned with strategic business imperatives of CCHI * Participate in the strategy planning process of CCHI to understand business priorities and impact on information systems, technologies and programs * Actively partner with and challenge the CCHI leadership in crafting the IT demand and needs * Provide insights of new technology developments and advice on how this can impact/contribute to the business strategy of CCHI * Collaborate with CCHI to build a Business Plan that indicates the impact of their business strategy on the products/services, processes, information systems and technologies and the migration path towards the future landscape * Ensure the support of IT and CCHI partners to drive the business plan as required * Drive prioritization, consolidation and alignment for the IT financial planning (Strategic and Annual Operating Plans.) * Act as a focal point between CCHI leadership and IT * Monitor quality, progress and performance of programs and take all necessary corrective actions to ensure that all elements of the business information plans are being delivered * Monitor quality, effectiveness and efficiency of our IT services * Communicate and report performance of IT services and programs towards relevant IT and CCHI partners * Lead the IT MDT (multidisciplinary team) to deliver best-in-class IT services, support and programs for CCHI * Communication and coordination with BE and ITLT on regulatory trends, initiatives, and programs, to enable advance IT planning, staffing and budgeting To succeed in this role, you should have the following skills and experience: * Overall business experience of 10-15 years * Masters degree, MBA, or other post graduate work required * Hands-on experience in different IT program roles * Successfully led multiple programs (5-8) in varying stages at the same time * Successfully led cross functional teams, often located across the globe * Worked successfully within differing business cultures, a wide variety of country cultures * Successfully led through influence rather than direct management Required knowledge and capabilities: * Strong business insight, overall and in primary subject matters * Strategic partnering and partner management * IT (Technology) Domain knowledge * Service portfolio management * Business Transformation Management * Project Management and Six Sigma experience / certification a plus * Lean experience /certification a plus * Strong mentoring skills * Strong analytical, problem solving and troubleshooting skills * Excellent communications and interpersonal skills Soft skills / leadership competencies: * Strong personal presence and awareness * Strong executive partner management * Empathetic with a strong sense for cultural differences and how to bridge them * High level of integrity * Ability to prioritize work based upon changing demands; proven sense for operational priorities * Ability to make decisions within uncertainty * Can work both independently and in remote project team setting * Enjoys working in a team environment and have a willingness to share knowledge * Powerful Communications & Influencing In return, we offer you A path towards your most rewarding career. Philips is growing its marketing capability enterprise wide. Succeeding in this market-based role in a complex environment will open many doors for your long term career, in other areas in Philips or otherwise. We also believe that we are at our best as a company when you are at yours as a person. Thus, we offer competitive health benefits, a flexible work schedule and access to local well-being focused activities. Why should you join Philips? Philips is more than a job. It's a calling to create a healthier society through meaningful work, focused on improving 3 billion lives a year by delivering innovative solutions across the health continuum. Our people experience a variety of unexpected moments when their lives and careers come together in meaningful ways. To find out more about what it's like working for Philips at a personal level, visit the Working at Philips page on our career website, where you can read stories from our employee blog. Once there, you can also learn about our recruitment process, or find answers to some of the frequently asked questions. It is the policy of Philips to provide equal employment and advancement opportunities to all colleagues and applicants for employment without regard to age, color, citizenship, disability or perceived disability, ethnicity, gender, gender identity or expression, genetic information, marital or domestic partner status, military or veteran status, national origin, pregnancy/childbirth, race, religion, sexual orientation, or any other category protected by federal, state and/or local laws. Philips is an equal employment opportunity and affirmative action employer Disability/Veteran. As an equal opportunity employer, Philips is committed to a diverse workforce. In order to ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veterans' Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants that require accommodation in the job application process may contact 888-367-7223, option 5, for assistance. #li-ph1 Contact If you forgot your password, you can click the Forgot Password button on the Sign In screen to reset it. In case of technical difficulties, please send an email to careersite@philips.com. (Note: To ensure fairness and legal compliance in our recruitment processes, only technical issues will be monitored through the above inbox. Please do not submit resumes or applications to this email, as they will not be reviewed. Only applications received through the online application process will be considered.) Philips Bothell WA

Manager, Healthcare Services ( Prior Authorizations )

Molina Healthcare