Director, Operational Oversight (Claims)
Molina Healthcare Ann Arbor, Michigan; Jacksonville, Florida; Sioux City, Iowa; Orem, Utah; Des Moines, Iowa; Rochester, New York; Ohio; Texas; Spokane, Washington; Albany, New York; Bellevue, Washington; San Antonio, Texas; Santa Fe, New Mexico; Meridian, Idaho; Mesa, Arizona; Kenosha, Wisconsin; Rio Rancho, New Mexico; Miami, Florida; Long Beach, California; Omaha, Nebraska; Iowa City, Iowa; Orlando, Florida; Savannah, Georgia; Lincoln, Nebraska; Fort Worth, Texas; Augusta, Georgia; Wisconsin; Utah; Georgia; Austin, Texas; St. Petersburg, Florida; Davenport, Iowa; Racine, Wisconsin; Owensboro, Kentucky; Syracuse, New York; Salt Lake City, Utah; Sterling Heights, Michigan; Columbus, Georgia; Kearney, Nebraska; Cedar Rapids, Iowa; Atlanta, Georgia; Houston, Texas; Green Bay, Wisconsin; Dayton, Ohio; Akron, Ohio; Boise, Idaho; Phoenix, Arizona; Cleveland, Ohio; Dallas, Texas; Warren, Michigan; Idaho; Vancouver, Washington; Everett, Washington; Nampa, Idaho; Covington, Kentucky; West Valley City, Utah; Albuquerque, New Mexico; Las Cruces, New Mexico; Chandler, Arizona; Cincinnati, Ohio; Louisville, Kentucky; Roswell, New Mexico; Michigan; Nebraska; Yonkers, New York; New Mexico; Florida; Scottsdale, Arizona; Bellevue, Nebraska; Caldwell, Idaho; Tacoma, Washington; Madison, Wisconsin; Grand Rapids, Michigan; Buffalo, New York; Tampa, Florida; Tucson, Arizona; Grand Island, Nebraska; Macon, Georgia; Iowa; Kentucky; Washington; New York; Layton, Utah; Bowling Green, Kentucky; Lexington-Fayette, Kentucky; Columbus, Ohio; Detroit, Michigan; Idaho Falls, Idaho; Provo, Utah; Milwaukee, Wisconsin Job ID 2032574
Job Description
Job Summary
Responsible for planning, developing and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve
Knowledge/Skills/Abilities
Responsible for the oversight of regulatory compliance of Corporate Operations functions, including but not limited to performance of internal compliance audits, represent Corporate Operations on external regulatory or associated audits, oversee function support areas requiring consistent oversight. May include travel up to 25%.
• Primary liaison between regulatory auditors and corporate operations business units, leadership and line personnel from receipt of notification from regulatory agency through analysis and response to findings.
• Organize audit submissions, interact directly with auditors for all lines of business as it relates to audits.
• Delegation Oversight; voting representative for delegation oversight committees.
• Liaison to Special Investigative Unit regarding program integrity and oversight cost expenditure.
• Monitor internal compliance of Corporate Operations units via establishment of an internal compliance program, including annual, periodic, focal, etc. audits.
• Request, review and perform oversight of internal corrective action plans (CAPs) for both internal and external audit findings via coordination of responses to assure appropriateness as it relates to the finding.
• Performs support via review and approval for Corporate Operations policies, procedures, guidelines and job aids to assure compliance with corporate or state regulations.
• Develop and maintain Corporate Operations Compliance program, including compliance policies, procedures and implementation of audits and monitoring.
• Corporate Operations liaison to Corporate Legal to address legal actions, e.g. third party liability suits, provider and other such member suits.
• Maintain an awareness of current laws, regulations, statutes, etc. for each state that Molina operates in that impacts Corporate Operations compliance.
• Analyze and interpret with possible assistance from Molina Health Plans regulations that affect Corporate Operations policies, procedures and guidelines and work with internal leadership to assure inclusion in such documents.
• Liaison for health plans for all OIG, OAG and other state office of internal/attorney general requests for data.
• Liaison with the corporation's special investigative unit.
• Assists with Request for Proposal responses.
• Proactively work with Corporate Operations leadership on operational effective to assure compliance.
• Persuade and instill effective cooperation to assure compliance via developing rapport with health plan compliance and government contract personnel..
Job Qualifications
Job Summary
Responsible for planning, developing and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve
Knowledge/Skills/Abilities
Responsible for the oversight of regulatory compliance of Corporate Operations functions, including but not limited to performance of internal compliance audits, represent Corporate Operations on external regulatory or associated audits, oversee function support areas requiring consistent oversight. May include travel up to 25%.
• Primary liaison between regulatory auditors and corporate operations business units, leadership and line personnel from receipt of notification from regulatory agency through analysis and response to findings.
• Organize audit submissions, interact directly with auditors for all lines of business as it relates to audits.
• Delegation Oversight; voting representative for delegation oversight committees.
• Liaison to Special Investigative Unit regarding program integrity and oversight cost expenditure.
• Monitor internal compliance of Corporate Operations units via establishment of an internal compliance program, including annual, periodic, focal, etc. audits.
• Request, review and perform oversight of internal corrective action plans (CAPs) for both internal and external audit findings via coordination of responses to assure appropriateness as it relates to the finding.
• Performs support via review and approval for Corporate Operations policies, procedures, guidelines and job aids to assure compliance with corporate or state regulations.
• Develop and maintain Corporate Operations Compliance program, including compliance policies, procedures and implementation of audits and monitoring.
• Corporate Operations liaison to Corporate Legal to address legal actions, e.g. third party liability suits, provider and other such member suits.
• Maintain an awareness of current laws, regulations, statutes, etc. for each state that Molina operates in that impacts Corporate Operations compliance.
• Analyze and interpret with possible assistance from Molina Health Plans regulations that affect Corporate Operations policies, procedures and guidelines and work with internal leadership to assure inclusion in such documents.
• Liaison for health plans for all OIG, OAG and other state office of internal/attorney general requests for data.
• Liaison with the corporation's special investigative unit.
• Assists with Request for Proposal responses.
• Proactively work with Corporate Operations leadership on operational effective to assure compliance.
• Persuade and instill effective cooperation to assure compliance via developing rapport with health plan compliance and government contract personnel..
Job Qualifications
Required Education
Bachelor's Degree or equivalent years of experience in Healthcare Administration such as oversight, audit, etc.
Required Experience
• 7 years of managed care experience (Regulatory and Compliance)
• Previous management experience of 5 years or more
Preferred Education
Master's Degree in Healthcare Administration
Preferred Experience
• 10 years of managed care experience (Regulatory and Compliance)
• Previous management experience of 5 years or more
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.
Pay Range: $101,721 - $206,981 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 07/11/2025ABOUT OUR LOCATION
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