Chief risk officer serp_jobs.h1.location_city

JOB DESCRIPTION Job Summary

Provides executive level strategy and leadership to a national business segment (i.e. Medicare, Marketplace, advanced imaging / central utilization management services) in the development and execution of care management, utilization management and disease management programs. Develops clinical practice guidelines and oversees appropriateness and medical necessity of services provided to plan members - targeting improvements in efficiency and satisfaction for members and providers. Partners with executive leadership team to provide cohesive direction towards company goals. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Provides executive strategy, vision and direction for the medical program for a designated Molina product(s). Responsible for performance and financial results, and keeps executive leadership apprised.
• Leads analysis of medical care cost and utilization data.
• Leads and manages the development of techniques to effectively correct identified and anticipated utilization problems while assuring that members receive the care they need.
• Offers a positive leadership role in key segment / product medical management initiatives aimed a optimizing utilization of medical resources.
• Establishes and / or leads the following types of national programs / initiatives using clinical and industry best practices : post-acute care (“SNFist” skilled nursing facility programs), model of care, palliative care, diabetes prevention, home health, prior authorizations / referrals.
• Provides national best practice strategic direction and oversight for segment population management (including care management, utilization management, auditing and training).
• Creates necessary cross-functional forums and uses data analysis to identify opportunities for medical cost trend and quality improvement to positively influence member care outcomes.
• Leads development and implementation of national medical policy, including recommendations for modifications to improve efficiency and effectiveness; designs standardized protocols, develops policy and ensures timely implementation in collaboration with health plan presidents and segment leadership, in addition to the enterprise clinical policy committee.
• Ensures compliance with medical policy and maintaining compliance with all federal, state and local regulatory guidelines.
• Designs standardized protocols, develops policy and ensures timely implementation with corporate and health plan input.
• Ensures adequate training occurs from knowledgeable staff and coordinates with other departments as needed.
• Focuses on continual refinement of operational processes by using process improvement principles (PDSA, Lean Six Sigma, etc.).
• Develops, performs and promotes interdepartmental integration and collaboration to enhance clinical services.
• Manages and evaluates team members in the performance of various clinical management activities.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Collaborates with other functional areas that interface with the segment including medical management, network contracting and provider relations, member services, claims management, payment integrity, pharmacy, quality and risk adjustment.
• Acts as a critical segment clinical leader for external providers, regulatory (local, state and federal) and accrediting agencies.
• Identifies potential areas of non-compliance by overseeing audits and provides advice and guidance to operational areas regarding effective processes, and policies and procedures.
• Collaborates with internal and external business partners to provide guidance and recommendations around the development, maintenance and enhancement of programs, products and services.
• Accountable for segment readiness for internal and external audits (local, state and federal) and the administration of industry best practices.
• Ensures appropriate preparation and the successful outcome of the utilization management program compliance audits.
• Ensures department policies, procedures and activities maintain adherence to, and are compliant with all state, federal, and delegating entity regulations and policies.
• Supports special / enterprise projects.

Required Qualifications

Preferred Qualifications

To all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.

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

Pay Range : $283,189.04 - $552,219 / ANNUAL