Supervisor, Care Review (RN) Utilization Management

California Preferred

JOB

DESCRIPTION

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.

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.

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.

Excellent knowledge of InterQual

/ MCG guidelines and Managed Care (MCO)

Preferred License,

Certification, Association

Active, unrestricted Utilization Management Certification

(CPHM), Certified Professional in Health Care Quality (CPHQ), or

other healthcare or management certification.

Work Schedule M-F,

some weekend and holiday support hours are also

required.

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.

Pay Range : $76,425 - $149,028 /

ANNUAL

• Actual compensation may vary from posting based

on geographic location, work experience, education and / or skill

level.