Dir – Corp Care Access & Monitoring

Director - Corporate Care Access Monitoring - RN

Plans, develops, enhances and directs enterprise wide Care Access and Monitoring, as well as Care Transitions, activities. Develops and implements effective and efficient programs, policies and reports that support corporate objectives, accrediting and regulatory standards and requirements. Works with the Corporate AVP Care Access and Monitoring to develop, implement and maintain quality standards of care in accordance with current Federal and State standards, guidelines and regulations. Also develops and implements standardized protocols, processes, reports and benchmarks that support continual enhancement of Healthcare Services functions to promote quality health care for members. Also works with other corporate teams as required to implement/enhance HCS operations in new states, acquisitions, product start-ups, and existing plans.

• Plans, develops, enhances and directs standardized enterprise wide Healthcare Services programs that comply with State/Federal regulatory requirements.
• Oversees Care Transition program activities.
• Works with other Corporate teams as required to implement Care Access and Monitoring and Care Transition operations in new states, acquisitions, product start-ups, and existing Health Plans.
• Assists Molina Health Plans compliance efforts with NCQA audits and state regulatory requirements.
• Develops and implements standardized policies and procedures, protocols, procedures, reports and benchmarks that support and further enhance the Healthcare Services function to promote quality, cost effective healthcare for Molina members.
• Project lead for ICD-10 conversion for Clinical Programs and Medical Policy.
• Works in conjunction with MHI and Health Plan associates to gain efficiencies, monitor compliance, and reduce costs throughout the enterprise.
• Develops and maintains standardized MHI documents and processes to continually improve HCS operations and carry out Molina clinical strategy.
• Focuses on continual refinement of operational processes within the Clinical Programs. Clearly articulate project requirements and anticipated outcomes to the Molina Project Management Office (PMO) for identified projects/strategies to improve the efficiency of the clinical operations to meet cost and quality goals.
• Conducts quality audits across all Plans as appropriate.
• Monitors performance standards across all Plans as appropriate.
• Participate in new business opportunities by responding to relevant sections of Request for Proposal documents.
• Assists new and existing states with HCS program/requirements.
• Represents HCS programs for system upgrades, including suggesting, documenting and reviewing enhancements with appropriate staff.
• Collaborates with Corporate Clinical Trainer regarding HCS training materials.
• Assists in budgetary process with AVP of Care Access and Monitoring
• Meet budget targets
• Travel will be required to help support these functions.
 

• Strong knowledge and experience with Medicaid utilization management and case management programs and regulatory requirements
• Knowledge of applicable state, federal and third party regulations and standards
• Program development and implementation
• Analytical problem solving capabilities, and operational and process improvement skills
• Ability to manage in a team building atmosphere
• Excellent interpersonal and 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)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
 

Required Education:
Bachelor’s Degree required Preferred Education:
Master’s Degree preferred

Required Experience:
• 5 years management experience with managed care.
• 5 years utilization/quality management experience.
• 3 years Clinical Nursing.
• Healthcare information systems experience.
• Experience developing and writing policies and procedures
• Experience developing performance measures that support Medicare HCS objectives:
Preferred Experience:
 

Required Licensure/Certification:
RN with active, unrestricted license Preferred Licensure/Certification:
CCM, CPHM, CPHQ Certification
 

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