Supervisor, Care Review (RN) Utilization Management

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.