Lead, Healthcare Services (Utilization Management) - Remote in FL

Job Title

Must reside in Florida

Job Summary

Provides lead level clinical support to healthcare services team supporting one or more of the following functions: care management, utilization management, care transitions, long-term services and supports (LTSS), behavioral health, and other clinical programs, and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

Provides level support to healthcare services department staff - devising/implementing delegation assignment strategies, facilitating healthcare services processes and communicating/coordinating activities.

Resolves issues and complaints that arise in day-to-day healthcare services operations and communicates escalation issues to healthcare services leadership.

Assists in training of healthcare services staff according to department standards, policies and procedures.

Maintains a minimal caseload to ensure adherence to appropriate guidelines and provide assistance to staff who have an ongoing member caseloads that may required additional support.

Collaborates with and keeps healthcare service leadership apprised of operational issues, staffing issues, system and program needs.

As a subject matter expert clinical lead, provides support, recommendations and education as appropriate to all other clinical and non-clinical staff.

Monitors healthcare services staff workload for adherence to policies, procedures, guidelines, and program specific requirements.

Actively participates in the department auditing program to review, communicate findings and identify opportunities for improved quality and compliance.

Shares quality and productivity scores with individual staff for awareness.

Provides feedback to healthcare services leadership on staff performance issues and consults with leadership on corrective action as necessary for performance improvement.

May collaborate with leadership to ensure the daily authorization reconciliation report (DARR) is run each work day and cases found non-compliant or missing compliance elements are remediated promptly.

May collaborate with leadership ensuring the care management monitoring tool (CMMT) is run every work day and cases are addressed to maintain health rid assessment (HRA) and care plan compliance.

Acts as liaison to both internal and external customers on behalf of both Molina and healthcare services department areas.

Maintains confidentiality, effective workplace relationships and adheres to company code of conduct.

Attends/participates in departmental, company-wide, and external committees, task forces, or work groups as assigned.

Local travel may be required (based upon state/contractual requirements).

Required Qualifications

At least 4 years experience in health care, and at least 2 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or equivalent combination of relevant education and experience.

Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master Social Worker (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.

Demonstrated knowledge of community resources.

Proactive and detail-oriented.

Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.

Ability to work independently, with minimal supervision and demonstrate self-motivation.

Responsive in all forms of communication.

Ability to remain calm in high-pressure situations.

Ability to develop and maintain professional relationships.

Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.

Excellent problem-solving, and critical-thinking skills.

Strong verbal and written communication skills.

Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

Registered Nurse (RN). License must be active and unrestricted in state of practice.

Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification.

Medicaid/Medicare population experience.

Clinical experience.