Advanced Practice Nurse Practitioner

JOB DESCRIPTION Job Summary

Provides medical oversight and expertise in appropriateness and medical necessity of health care services provided to plan members - targeting improvements in efficiency and satisfaction for member patients and providers, in addition to meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Demonstrates and facilitates conformance to Medicare, Medicaid, National Committee for Quality Assurance (NCQA) and other regulatory requirements.
• Reviews quality referred issues, focused reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and others as directed by the chief medical officer.
• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements plan medical policies.
• Provides implementation support for quality improvement activities.
• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions if needed.
• Collaborates with contracting department in contract negotiations.
• Fosters clinical practice guideline implementation and evidence-based medical practices.
• Utilizes information technology and data analysts to produce tools to report, monitor and improve utilization management.
• Actively participates in regulatory, professional and community activities.

Required Qualifications

Preferred Qualifications

To all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V

Pay Range : $117,731 - $275,491 / ANNUAL