Molina Healthcare

Compensation

Full Description

JOB DESCRIPTION Job Summary Provides advanced clinical and operational expertise to ensure delegated clinical functions – such as Utilization Management (UM), Care Management (CM), Behavior Health (BH), Disease Management (DM), and Quality programs – meet expected financial and clinical outcomes, organizational contractual, regulatory, and accreditation (NCQA, CMS, State) requirements. Leads end-to-end oversight activities, including performance monitoring, audits, corrective action management, risk identification, process improvement, and continuous performance optimization across delegated clinical entities. Partners with HCS clinical leaders, Finance, Medical Economics and other internal business owners, Compliance, Quality, Legal and Executive Leadership to ensure vendors deliver high-quality, cost-effective, and compliant services to members. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties Provides advanced clinical and operational expertise to ensure delegated functions (UM, CM, BH, DM and Quality programs) meet clinical, financial, contractual, regulatory and accreditation requirements (NCQA, CMS, State). Conducts end-to-end oversight of delegated clinical entities, including performance monitoring, audits, corrective action plans (CAPs), and risk identification. Assesses business and operational impacts and needs related to the clinical delegation functions to identify opportunities to improve efficiency, accuracy, productivity, and effectiveness. Collaborates with internal partners to ensure high-quality, cost-effective vendor performance. Conducts Joint Operating Committees (JOCs) and other required meetings, and disseminates communications related to vendor performance, action plans, and improvement activities with key stakeholders. Reviews, researches, analyzes and evaluates delegated vendor information and processes, to assess compliance between a process or function and the corresponding written documentation. Uses analytical skills to identify variances. Uses problem-solving skills and business knowledge to make recommendations for process remediations or improvements. Uses understanding of key revenue levers, cost drivers and member and provider satisfaction impacts of business processes, to optimize and improve vendor performance. Employs change management techniques to prepare the business for successful organizational change initiatives. Translates metric-driven findings into actionable strategy recommendations for leadership and operational teams. Partners with Data/BI teams to enhance automation, data accuracy, and predictive analytics capabilities. Serves as the central point of escalation for vendor performance issues, coordinating with Clinical Operations, Quality, Compliance, IT, Finance, and Contracting. Collaborates with Contracting to optimize performance requirements, financial terms tied to outcomes, and measurable reporting standards. Required Qualifications At least 6 years of experience in health care, preferably in a clinical consultancy process improvement capacity, or equivalent combination of relevant education and experience. Registered Nurse (RN), license must be active and unrestricted in state of practice. Understanding clinical operations including utilization management and care management. Ability to provide hands-on, immersive, and direct support for identified business improvement initiatives. Experience in performance management activities and execution of corrective action plans. Strong leadership qualities and ability to lead and achieve results. Excellent verbal and written communications skills. Microsoft Office suite/applicable computer programs proficiency. Preferred Qualifications LEAN or Six Sigma certification. Experience in tracking and maintaining quality metrics. 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