RN Lead, Healthcare Services

Molina Healthcare•Long Beach, CA

About The Position

Provides lead level clinical support to the healthcare services team, supporting 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 toward desired outcomes and contribute to a strategy of quality and cost-effective member care.

Requirements

At least 4 years of experience in healthcare.
At least 2 years of managed care experience in utilization management.
Registered Nurse (RN) ONLY if required by state contract, regulation 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.
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.
Microsoft Office suite/applicable software program(s) proficiency.

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 Quality (CPHQ) or other health care or management certification.
Medicaid/Medicare population experience.
Utilization Management experience.

Responsibilities

Provides lead support to healthcare services department staff, including devising and implementing delegation assignment strategies, facilitating processes, and coordinating activities.
Resolves issues and complaints in daily operations and escalates issues to 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, staffing, system, and 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.
Participates in the department auditing program to review findings, communicate them, and identify opportunities for quality and compliance improvement.
Shares quality and productivity scores with individual staff.
Provides feedback to healthcare services leadership on staff performance issues and consults on corrective action.
May collaborate with leadership to ensure the daily authorization reconciliation report (DARR) is run and non-compliant cases are remediated.
May collaborate with leadership to ensure the care management monitoring tool (CMMT) is run and cases are addressed for HRA and care plan compliance.
Acts as a liaison to internal and external customers on behalf of Molina and healthcare services departments.
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.