Job Description Ohio Plan Specific: This role is part of our Utilization Management team. You would be supervising a team of Seasoned Nurses who are responsible for the Prior Authorization and evaluation of medical needs for our members. This role would be great for an experienced Nurse from the Medical Surg background.
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 - Oversees an integrated Care Access and Monitoring team responsible for prior authorizations, inpatient/outpatient medical necessity/utilization review, and/or other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time.
- Functions as a hands-on supervisor, coordinating and monitoring clinical and non-clinical team activities to facilitate integrated, proactive utilization management, ensuring compliance with regulatory and accrediting standards.
- Manages and evaluates team members in the performance of various utilization management activities; provides coaching, counseling, employee development, and recognition; and assists with selection, orientation and mentoring of new staff.
- Performs and promotes interdepartmental integration and collaboration to enhance the continuity of care including Behavioral Health and Long Term Care for Molina members.
- 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.
- Completes 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.
Qualifications Job Qualifications Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.
Required Experience - 3+ years clinical nursing experience.
- 2+ years utilization management experience.
- Experience demonstrating leadership skills.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) in good standing.
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
Bachelor's or Master's Degree in Nursing, Health Care Administration, Public Health or related field.
Preferred Experience 5 years clinical practice with managed care, hospital nursing or utilization management experience.
3+ years supervisory experience in a managed healthcare environment.
Preferred License, Certification, Association
Utilization 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.
