VP, Core OperationsLong Beach, California Job ID 2000584
Under the general direction the SVP, Core Operations is responsible for the strategy, design, and implementation of companywide initiatives impacting one or more of the following areas:
• Claims Production (i.e. Claims Production, Audit, Production Vendor Oversight) for all lines of business
• Claims Shared Services for all lines of business (i.e. activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Corporate Encounter Team, Appeals and Grievance Team as well as providing overall organizational leadership aimed at managing overall healthcare costs)
• Corporate Configuration of the QNXT system for all lines of business, which may also include the Care Management application for UM functions within QNXT
• Member/Provider Appeals and Grievances including claims disputes, meeting state regulatory requirements, enabling the system to produce expected health care costs, maximizing MASS Adjudication within QNXT, improving the quality of the provider payment process, reducing G&A costs as measured by both Unit Claims Costs and on a per member per month basis in each of the areas reporting to the Core Ops Team as part of the enterprise wide efforts to meet or exceed budget targets and to consistently to reduce G&A, continuing to drive positive operational and financial outcomes within the other Provider Payment Initiatives reporting up to the Core Ops Team.
• Hires, coordinates training and manages staff involved in creating controls, documents and tools within the Member/Provider Appeals & Grievances and Claims Dispute area reporting to the Core Ops Team in order to manage work in any of the assigned Corporate Operations areas for all lines of business.
• Identifies, develops and trains appropriate staff and implements processes to standardize the overall ends-to-end processing of appeals and grievances, as well as working with partner departments to implement process improvements impacting quality and timeliness of processing appeals and grievances.
• Initiates staff and coordinates needed projects around various systems enhancements, conversions and upgrades. These projects improve QNXT Claims MASS Adjudication results, enhances the Corporate Operations claims quality and reduces unit claims costs by reducing rework (both underpayments and overpayments) for all lines of business.
• Identifies projects/initiatives that reduce administrative costs for Molina and/or providers as well as identifies opportunities to ensure accurate claims editing is occurring to assist in the management of the organizational health care costs for all lines of business. Convenes work groups, develops implementation plans with identified tasks, timelines and assigned parties. Executes and measures success.
• Participates with others in the Corporate Operational Leadership Team along with IT to analyze the root cause of information of variations to the claims payment, to find/propose ways to improve upon performance results, to identify potential risks to the organization and to lead the needed changes within the claims process to support the organizational needs in all lines of business.
• Collaborate with leadership, peers, and business partners to establish inquiry, disputes & appeal improvement objectives and execute business priorities based on strategic goals in the operational plan.
• Works with the Training Team in preparing needed documentation around training of new/existing staff while also assisting in preparing needed Guidelines to assist in the timely and accurate processing of appeals, grievances, and disputes for all lines of business.
• Manages direct Molina staff as well as oversees vendors involved in any of the areas reporting to the VP, Core Operations to enable the organization to produce operational results at the lowest possible cost, the most consistent and compliant service levels and the highest level of quality for all lines of business.
• Ensures all state, federal and Molina regulations, Policies/Procedures and SOPs are implemented and followed on a consistent basis to ensure the highest compliance possible within the Corporate Operations areas.
• Sets and manages overall costs to meet/exceed annual budgets set for each or all of the areas in reporting to the Core Ops VP, and finds ways to improve productivity and automation wherever possible to reduce unit costs and overall G&A for the organization.
• Design and implement systematic approach to improve member and provider experiences through increased operational efficiency and effectiveness.
• Responsible for reporting potential liabilities for financial tracking and accruals to senior leadership.
• Excellent verbal and written communication skills
• Ability to influence and drive change among peers and others within the Molina organization
• Skill to envision, craft proposals, obtain consensus around approving and implementing future state processes and systems needed to support strategic direction set by organization.
• Ability to abide by Molina's policies
• Ability to maintain attendance to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
• Other duties as assigned
Minimum of 10 years Healthcare experience in related job or Operational experience.
4 years minimum in Director level role or above.
Accountability for multiple markets or product lines.
Experience developing and managing department budget within prescribed parameters.
Experience with account management responsibilities with senior level leadership.
Master's Degree or appropriate relevant healthcare experience (with minimum of 7 years for relevant Master's degree)
Experience implementing process improvements in a matrix environment.
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.