Director, Inpatient Utilization Management (Rn)

Molina Healthcare; San Jose (CA); Hybrid; USD 102,000 - 198,000; Full time

Job summary

Molina Healthcare in California is seeking a senior healthcare services leader responsible for utilization management, care management and related programs. You will guide a multidisciplinary team, drive collaboration across departments, and ensure compliant, cost-effective member care.

The role requires CA RN licensure or equivalent, 8+ years in health care with 5+ in managed care, and strong leadership to execute strategic plans and improve outcomes.

Qualifications

• Minimum 8 years healthcare experience with 5+ years in managed care.
• At least 3 years healthcare management/leadership.
• RN/LPN/LCSW/LMFT/LPCC/LMSW licensure as applicable.
• Experience with state, federal and third-party regulations.
• Ability to lead through change and manage conflicts.
• Strong written and verbal communication skills.

Responsibilities

• Directs and oversees care management, utilization management, LTSS, behavioral health or related programs.
• Develops and monitors standardized protocols for clinical and non-clinical teams.
• Promotes interdepartmental integration to enhance clinical services.
• Collaborates with senior leadership and presents solutions/action plans.
• Facilitates committees and multidisciplinary teams for enterprise-wide programs.
• Ensures monthly auditing with appropriate follow-up.
• Engages in clinical training activities and mentorship.
• Local travel may be required based on state/contractual requirements.

Skills

Healthcare leadership

RN/licensed clinician

Regulatory compliance

Cross-functional collaboration

Leadership

Microsoft Office

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Work Location: California - Ability to work remote, but selected candidate must reside in the state of California.

This position requires California RN Licensure. Candidates must have significant IPA delegation experience.

Leads and directs a multidisciplinary team of healthcare services professionals in some or all of the following functions: utilization management, care management, behavioral health and other programs. Leads team responsible for assessing, facilitating, planning and coordinating integrated delivery of care across the continuum. Participates with senior leadership to establish strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• • Directs and oversees one or more of the following key health care services functions: care management, utilization management, care transitions, long-term supports and services (LTSS), behavioral health, nurse advice line, and/or other special programs.
• • Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care coordination/care review and management.
• • Develops and promotes interdepartmental integration and collaboration to enhance clinical services.
• • Collaborates with and keeps healthcare services senior leadership informed of operational issues, staffing, resources, system and program needs and presents solutions/action plans for issues.
• • 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.
• • Ensures monthly auditing is occurring with appropriate follow-up.
• • Engages in clinical training activities and outcomes.
• • Develops and mentors direct reporting healthcare services leadership.
• • Local travel may be required (based upon state/contractual requirements).

Required Qualifications

• •At least 8 years health care experience, and 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 equivalent combination of relevant education and experience.
• • At least 3 years health care management/leadership required.
• • 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.
• • Experience working within applicable state, federal, and third party regulations.
• • Ability to manage conflict and lead through change.
• • Operational and process improvement experience.
• • Ability to work cross-collaboratively across a highly matrixed organization.
• • Ability to prioritize and manage multiple deadlines.
• • Excellent organizational, problem-solving and critical-thinking skills.
• • Strong written and verbal communication skills.
• • Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• • 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.

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

Pay Range: $101,721 - $198,356 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.