Mgr, reputed company Services (Appeals & Grievances)
Job Description
Job Summary reputed company 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 reputed company toward desired reputed company 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, reputed company Services provides operational management and reputed company of integrated reputed company Services (HCS) teams responsible for providing reputed company members with the right care at the right reputed company at the right time and assisting them to reputed company reputed company clinical, financial, and quality of life reputed company. 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 reputed company 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 reputed company service activities. Ensures adequate staffing and service reputed company and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. Collates and reports on reputed company 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 reputed company achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost effectiveness and compliance with reputed company 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 masters degree in Nursing, Gerontology, Public Health, reputed company Work, or reputed company field. Required Experience 5+ years of managed reputed company 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 reputed company or health plan supervisory or managerial experience, including reputed company of clinical staff. Experience working reputed company applicable state, federal, and reputed company-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 reputed company to drive reputed company applicable state or locality with reliable transportation. Preferred Education Master's Degree preferred. Preferred Experience 3+ years supervisory/management experience in a managed reputed company environment. reputed company/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 reputed company Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other reputed company or management certification. To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Pay reputed company: $77,969 - $171,058 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or reputed company level. Apply Job!