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

Molina Healthcare•Long Beach, FL

15h•Remote

About The Position

Provides lead level clinical support to the healthcare services team, focusing on functions such as care management, utilization management, care transitions, long-term services and supports (LTSS), and behavioral health. This role collaborates with a multidisciplinary team to coordinate integrated member care across the continuum, aiming to ensure member progress towards desired outcomes and contribute to the strategy of providing quality, cost-effective member care. The position requires the candidate to reside in Florida.

Requirements

At least 4 years of experience in healthcare.
At least 2 years of managed care experience in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or an equivalent combination of relevant education and experience.
Clinical licensure and/or certification required ONLY if mandated by state contract, regulation, business operating model, or state board licensing mandates. If licensed, the license must be active and unrestricted in the 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.
Ability to focus on multiple projects simultaneously and adapt to change.
Excellent problem-solving and critical-thinking skills.
Strong verbal and written communication skills.
Proficiency in Microsoft Office suite/applicable software programs.

Nice To Haves

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.

Responsibilities

Provides lead level support to healthcare services department staff, including devising and implementing delegation assignment strategies, facilitating healthcare services processes, and communicating/coordinating activities.
Resolves issues and complaints arising in daily healthcare services operations and escalates issues to healthcare services leadership.
Assists in training healthcare services staff according to department standards, policies, and procedures.
Maintains a minimal caseload to ensure adherence to guidelines and provide support to staff with ongoing member caseloads.
Collaborates with and keeps healthcare service leadership informed of operational issues, staffing issues, and system/program needs.
As a subject matter expert clinical lead, provides support, recommendations, and education to 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 findings, communicate them, 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 on corrective actions for performance improvement.
May collaborate with leadership to ensure the daily authorization reconciliation report (DARR) is run daily and non-compliant cases are remediated promptly.
May collaborate with leadership to ensure the care management monitoring tool (CMMT) is run daily and cases are addressed to maintain HRA and care plan compliance.
Acts as a liaison to internal and external customers on behalf of Molina and healthcare services department areas.
Maintains confidentiality, effective workplace relationships, and adheres to the 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.