RN Lead, Healthcare Services

JOB DESCRIPTION Job Summary

Provides lead level clinical support to healthcare services team supporting one or more of the following functions: care management, utilization management, care transitions, long-term services and supports (LTSS), behavioral health, and other clinical programs, and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Provides level support to healthcare services department staff - devising/implementing delegation assignment strategies, facilitating healthcare services processes and communicating/coordinating activities.
• Resolves issues and complaints that arise in day-to-day healthcare services operations and communicates escalation issues to healthcare services leadership.
• Assists in training of healthcare services staff according to department standards, policies and procedures.
• Maintains a minimal caseload to ensure adherence to appropriate guidelines and provide assistance to staff who have an ongoing member caseloads that may required additional support.
• Collaborates with and keeps healthcare service leadership apprised of operational issues, staffing issues, system and program needs.
• As a subject matter expert clinical lead, provides support, recommendations and education as appropriate to all other clinical and non-clinical staff.
• Monitors healthcare services staff workload for adherence to policies, procedures, guidelines, and program specific requirements.
• Actively participates in the department auditing program to review, communicate findings and identify opportunities for improved quality and compliance.
• Shares quality and productivity scores with individual staff for awareness.
• Provides feedback to healthcare services leadership on staff performance issues and consults with leadership on corrective action as necessary for performance improvement.
• May collaborate with leadership to ensure the daily authorization reconciliation report (DARR) is run each work day and cases found non-compliant or missing compliance elements are remediated promptly.
• May collaborate with leadership ensuring the care management monitoring tool (CMMT) is run every work day and cases are addressed to maintain health rid assessment (HRA) and care plan compliance.
• Acts as liaison to both internal and external customers on behalf of both Molina and healthcare services department areas.
• Maintains confidentiality, effective workplace relationships and adheres to company code of conduct.
• Attends/participates in departmental, company-wide, and external committees, task forces, or work groups as assigned. groups as assigned.
• Local travel may be required (based upon state/contractual requirements).

Required Qualifications

• At least 4 years experience in health care, and at least 2 years of managed care experienced in utilization management
• Registered Nurse (RN) ONLY if required by state contract, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication.
• Ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification.
• Medicaid/Medicare population experience.
• Clinical experience.

Prior experience overseeing Utilization Management processes, interQual, MCG guidelines, PEGA experience etc. 

Work schedule: full time daytime business hours, with some weekends and holiday support may be required.

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. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $29.05 - $56.64 / HOURLY
*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.