RN Manager Healthcare Services - Utilization Review

Molina Healthcare; Long Beach (CA); Remote; USD 80,000 - 110,000; Full time

Job summary

An established industry player is seeking a dedicated RN Manager to lead a utilization management team. This role involves overseeing clinical operations to ensure members receive optimal care while complying with regulatory standards. The ideal candidate will have extensive experience in managed healthcare, particularly in utilization and case management, and will be responsible for coaching and developing staff to achieve high-quality outcomes. This position offers a chance to make a significant impact in the healthcare sector, working collaboratively with a multidisciplinary team to enhance patient care and satisfaction.

Benefits

Competitive benefits package

Flexible schedule

Professional development opportunities

Qualifications

• 5+ years of managed healthcare experience with supervisory roles.
• Experience in utilization management and case management required.

Responsibilities

• Manage clinical teams performing care review and case management.
• Ensure compliance with regulatory standards and oversee staff performance.

Skills

Utilization Management

Leadership

Case Management

Healthcare Regulations

Clinical Oversight

Education

Bachelor's or Master's in Nursing

Equivalent combination of LVN or LPN with experience

Job description

JOB DESCRIPTION

For this position we are seeking a (RN) Registered Nurse who be licensed in the state they reside.

We are looking for a RN Manager to manage a utilization managementteam supporting 14 Marketplace plans.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM (Residing Time Zone) – Flexibility to cover any weekend time if needed

Preferred candidate with Utilization Management and leadership experience (Direct Reports)

Compact RN license strongly preferred

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

The Manager, Healthcare Services provides operational management and oversight of integrated Healthcare Services (HCS) teams responsible for providing Molina Healthcare members with the right care at the right place at the right time and assisting them to achieve optimal clinical, financial, and quality of life outcomes.

• Responsible for clinical teams (including operational teams, where integrated) performing one or more of the following activities: care review/utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), case management, transition of care, health management and/or member assessment.
• Typically, through one or more direct report supervisors, facilitates integrated, proactive HCS management, ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina Clinical Model.
• Manages and evaluates team member performance; provides coaching, counseling, employee development, and recognition; ensures ongoing, appropriate staff training; and has responsibility for the selection, orientation and mentoring of new staff.
• Performs and promotes interdepartmental/ multidisciplinary integration and collaboration to enhance the continuity of care including Behavioral Health and Long-Term Services & Supports for Molina members. Oversees Interdisciplinary Care Team meetings.
• Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
• Collates 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 and 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.
• Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate, while identifying opportunities for improvement.

JOB QUALIFICATIONS

Required Education

• Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license.
• OR Bachelor's or master’s degree in Nursing, Gerontology, Public Health, Social Work, or related field.

Required Experience

• 5+ years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition and/or disease management.
• Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff.
• Experience working within applicable state, federal, and third-party regulations.

Required License, Certification, Association

• If licensed, license must be active, unrestricted and in good standing.
• Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education

Master's Degree preferred.

Preferred Experience

• 3+ years supervisory/management experience in a managed healthcare environment.
• Medicaid/Medicare Population experience with increasing responsibility.
• 3+ years of clinical nursing experience.

Preferred License, Certification, Association

Any of the following:

Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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