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Director, Outpatient Utilization Management
3 months ago
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
Directs and oversees one of the following key Healthcare Services functions: case management/disease management/care transitions; utilization management (Position oversees PA authorizations and manages the inpatient certification review staff for initial, concurrent, or retrospective reviews); long-term supports and services; or nurse advice line.
Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care review and management.
Develops, performs, and promotes interdepartmental integration and collaboration to enhance clinical services.
Collaborates with and keeps the AVP or VP of Healthcare Services informed of operational issues, staffing, resources, system, and program needs and presents solution action plan for issues.
Facilitates and participates in committees, task forces, work groups and multidisciplinary teams as needed to promote standardized Molina enterprise-wide approach to Care Management programs.
Ensures monthly auditing is occurring with appropriate follow-up.
Engaged in clinical training activities and outcomes.
Develops and mentors HCS managers and supervisors.
This a full-time position.
JOB QUALIFICATIONS
Required Education
Bachelor's Degree in Healthcare-related field (equivalent combination of education, experience and/or Nursing license will be considered in lieu of Bachelor's Degree).
Required Experience
7+ years managed healthcare experience with line management responsibility including clinical operations.
Experience working within applicable state, federal, and third-party regulations.
Required License, Certification, Association
If licensed, license must be active, unrestricted and in good standing.
Preferred Education
Master's Degree in Business, Healthcare, Social Work, or related field.
Preferred Experience
10+ years managed care experience.
Operational and process improvement experience.
Preferred License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Utilization Management Certification (CPHM) Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
**Pay Range**: $79,607.91 - $172,483.8 / ANNUAL
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
