Manages the day to day integrated team of health plan based staff responsible for cost effective delivery of healthcare services for Molina members. Oversees staff responsible for establishing clinical, financial and educational goals for members to achieve high quality patient care and optimal outcomes. Monitors information daily as appropriate including member metrics and staff productivity. Evaluates the services provided and outcomes achieved by the team and recommends enhancements and/or improvements for programs and staff development to ensure consistent compliance with all state and federal regulations and guidelines in day-to-day activities.
• Oversees, coordinates and monitors all team activities to facilitate integrated proactive care management including Care Access and Monitoring, Case Management, Behavioral Health and Long Term Care.
• Manages and evaluates team members in the performance of various health management activities.
• Participates in the development and implementation of programs to meet the needs of Molina membership.
• Performs and promotes interdepartmental integration and collaboration to enhance the continuity of care for members.
• Evaluates program performance and participates in the development of enhancement strategies as needed.
• Ensures adequate staffing and service levels, and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Maintains effective team member relations.
• Conducts regular staff meetings (at least monthly).
• Assists with selection, orientation and mentoring of new team members.
• Conducts performance evaluations in a timely manner.
• Provides coaching, counseling and employee development and meets individually with staff at least monthly.
• Recognizes exceptional employee performance.
• Assists team members in improving skills, creativity and problem solving.
• Collaborates with and keeps the Healthcare Services Director appraised of operational issues, staffing, resources, system and program needs.
• Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities.
• Manages and completes assigned work plan objectives and projects on a timely basis.
• Participates in committees, task forces, work groups and multidisciplinary teams related as needed.
• Maintains professional relationships with provider community and internal and external customers while identifying opportunities for improvement.
• Participates in the development of policies and oversees staff activities to ensure compliance with regulatory and accrediting standards.
• Creates and ensures timely and accurate reporting to executive management and appropriate committees.
• Accountable for timely reports submission to regulatory agencies and Plan Partner(s) as required contractually.
• Acts as a liaison to both internal and external customers on behalf of both Molina and the Healthcare Services Team.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Acts as an information and problem solving resource for team members, physicians, hospitals, and other Molina staff.
• Interacts with medical directors regularly, as necessary.
• Facilitates open and timely communication between team members, other Molina employees and external customers.
• Complies with required workplace safety standards.
• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Skilled at managing high functioning interdisciplinary teams of professionals.
• Able to use effective management principles.
• Excellent organizational skills with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• Knowledge of ICD-9, CPT coding and HCPC.
• Knowledge of SSI, COB, and TPL programs and integration.
• Familiarity with NCQA standards, regulations and measurement techniques.
• Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• 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).
• Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
Registered Nurse, Bachelor’s degree or advanced practice nurse (equivalent combination of experience/education will be considered in lieu of Degree).
Three or more years of clinical nursing experience. Three years or more managed healthcare experience. Three years healthcare managerial experience.
Active, unrestricted State Registered Nursing license in good standing.
Master’s degree in Nursing or Health Related Field.
Five or more years in a management role in a Managed Care Environment.
Case Manager (CCM), Certified Professional Healthcare Management (CPHM) Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.
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