Job Description
Job Summary
Molina Health Plan Operations jobs are responsible for the development and administration of our State Health Plan's Operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.
Knowledge/Skills/Abilities
• Under the leadership of the VP, Health Plan Operations, plans, organizes, staffs, and coordinates the operations of the health plan for the Medicaid , CHIP, Marketplace, MMP and Medicare lines of business.
• Works with staff and senior management to develop and implement provider and member service strategies to improve access and satisfaction with the Plan.
• Serves alongside the VP, Health Plan Operations as liaison for MHI Operations, including: Claims, Configuration Information Management, Provider Data Management, Credentialing, Enrollment, and Contact Center Operations.
• Oversees Claims Operations and Configuration Information Management and works collaboratively with Corporate business owners to ensure the health plan processes for claims and encounters, aligns with regulatory requirements for each applicable line of business.
• Oversees Enrollment and Contact Center Operations to ensure compliance with health plan requirements. Works collaboratively with Corporate business owners to mitigate risk related to enrollment processes and call center performance.
• Oversees the Plan's Provider Network Administration activities, specifically ensuring that corporate staff receive data to load correct provider, contract and benefit configuration to support accurate claims payment and for development of accurate provider directories.
• Oversees Provider Credentialing activities to ensure compliance with regulatory requirements.
• Oversees the Provider Issue Research and Resolution function and the provider claim reconsideration process. Coordinates activities and executes strategies to address opportunities to improve provider satisfaction and reduce operational risk in conjunction with Provider Services.
• Oversees the Member Appeals and Grievance process; completes analytics to identify trends; and executes strategies to improve member satisfaction.
• Develops and executes effective member retention strategies to achieve desired retention goals. Also serves as a key partner with community outreach to achieve profitable growth.
• Business owner of Member Stakeholder Experience team initiatives, including member static website, member web portal and Customer Relationship Management (CRM) solution. Ensures compliance with regulatory requirements and successful communication and implementation with members, employees and other key stakeholders to limit operational impact.
Job Qualifications
Required Education
Bachelor's degree in Business, Health Services Administration or related field.
Required Experience
• 7-10 years' experience in Healthcare Administration, Managed Care, and/or Provider Services.
• 3-5 years' experience with STAR, CHIP and STAR+PLUS Operations
• 3-5 years' experience with Claims Prompt Pay laws
• Seasoned leader with experience managing/supervising employees.
• Demonstrated adaptability and flexibility to change and to new ideas and approaches.
Preferred Education
Master's degree in Business, Health Administration or related field.
Preferred Experience
- Experience with Medicaid and Medicare managed care plans.
- Data analytic skills - Excel.
- Claims
- Provider data management systems experience.
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.
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