Director, Healthcare Services; Utilization Management (WA)

Molina Talent Acquisition; Washington; Remote; USD 120,000 - 165,000; Full time

Job summary

Molina Healthcare seeks an experienced healthcare services leader to oversee utilization management, care management and behavioral health programs for Washington state, aligning with Molina's clinical model and regulatory standards.

The role develops standardized protocols, promotes cross-department collaboration, ensures staffing, and monitors performance metrics to drive cost-effective, high-quality care delivery while supporting PST hours.

Qualifications

• At least 8 years of health care experience with managed care exposure.
• At least 3 years of management/leadership experience.
• Clinical licensure and/or certification required depending on state mandates.
• Strong customer service and member-centric focus.

Responsibilities

• Oversees team performance for health services functions (utilization management, care management, behavioral health).
• Facilitates integrated care management with adherence to regulatory standards.
• Develops and monitors standardized protocols for clinical and non-clinical activities.
• Promotes interdepartmental integration to enhance clinical services.
• Ensures staffing adequacy, monitors productivity and performance indicators.
• Oversees program activities in accordance with contracts and accreditation.

Skills

Strong customer service skills

Excellent written and verbal in/from

Collaboration across matrixed orgs

Organizational and problem-solving

Prioritize multiple deadlines

Education

Nursing licensure (RN/LPN/LVN) or related licenses

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

This position will be remote, but candidate will need to be local to Washington state and support PST hours.

Essential Job Duties

• Oversees team performance for one or more of the following healthcare services functions: utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), behavioral health, and/or special programs.
• Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model.
• Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care coordination and management.
• Develops and promotes interdepartmental integration and collaboration to enhance clinical services.
• May function as a “hands-on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
• Assists in implementing utilization management, behavioral health, care transitions, and other program activities in accordance with regulatory, contract standards and accreditation compliance.
• Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence.
• Ensures high-risk, complex members are adequately supported.
• Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services.
• Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs, and presents solutions/action plans for remediation.
• Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care.
• Oversees interdisciplinary care team (ICT) meetings.
• Analyzes 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.
• Ensures completion of staff quality audit reviews evaluates services provided, 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.
• Facilitates and participates in committees, task forces, work groups and multidisciplinary teams as needed to promote a standardized enterprise-wide approach to healthcare services programs.
• Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate.
• Identifies opportunities for care delivery/quality/operational/etc. process improvements.
• Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals.
• Local travel may be required (based upon state/contractual requirements).

Required Qualifications

• At least 8 years of health care experience, including at least 5 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Strong customer service skills/member-centric focus.
• Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations.
• Ability to prioritize and manage multiple deadlines.
• Strong organizational and problem-solving skills.
• Ability to collaborate cross-functionally within a highly matrixed organization.
• Excellent written and verbal communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Clinical experience.
• Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice.
• Medicaid/Medicare population experience.

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