Medical Manager jobs at HCA Healthcare

- 99 jobs

Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Columbus, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Manager, Medical Economics (Medicaid) - REMOTE
Molina Healthcare 4.4
Akron, OH jobs
The Manager, Medical Economics provides support and consultation to the Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. **KNOWLEDGE/SKILLS/ABILITIES** Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. + Extract and compile information from various systems to support executive decision-making + Mine and manage information from large data sources. + Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. + Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. + Work with business owners to track key performance indicators of medical interventions + Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives + Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan + Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise + Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management + Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports + Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes + Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making + Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same + Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results + Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare **JOB QUALIFICATIONS** **Required Education** Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field **Required Experience** + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts **Preferred Education** Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. **Preferred Experience** + 3 - 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) + Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. \#PJCorp \#LI-AC1 Pay Range: $88,453 - $172,484 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$88.5k-172.5k yearly 60d+ ago
Manager, Medical Economics (Medicaid) - REMOTE
Molina Healthcare 4.4
Ohio jobs
The Manager, Medical Economics provides support and consultation to the Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. **KNOWLEDGE/SKILLS/ABILITIES** Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. + Extract and compile information from various systems to support executive decision-making + Mine and manage information from large data sources. + Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. + Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. + Work with business owners to track key performance indicators of medical interventions + Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives + Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan + Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise + Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management + Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports + Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes + Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making + Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same + Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results + Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare **JOB QUALIFICATIONS** **Required Education** Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field **Required Experience** + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts **Preferred Education** Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. **Preferred Experience** + 3 - 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) + Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. \#PJCorp \#LI-AC1 Pay Range: $88,453 - $172,484 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$88.5k-172.5k yearly 60d+ ago
Manager, Medical Economics (Medicaid) - REMOTE
Molina Healthcare 4.4
Long Beach, CA jobs
The Manager, Medical Economics provides support and consultation to the Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. Extract and compile information from various systems to support executive decision-making Mine and manage information from large data sources. Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. Work with business owners to track key performance indicators of medical interventions Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience 3 years management or team leadership experience 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) Strong Knowledge of SQL and PowerBI report development Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience 3 - 5 years supervisory experience Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans Experience with Databricks Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) Proficiency with Excel and SQL for retrieving specified information from data sources. Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. #PJCorp #LI-AC1
$50k-93k yearly est. Auto-Apply 37d ago
Hospice Medical Director - Remote Only, Per Diem, Flexible Schedule
Banner Health 4.4
Greeley, CO jobs
**Per Diem Hospice Medical Directorin Beautiful Northern, CO** **Remote Only & Flexible Schedule** **BANNER HEALTH and the Home Care & Hospice Division** , one of the countrys premier, nonprofit health care networks with more than 1,500 physicians and advance practice providers, **has an excellent opportunity for a compassionate, skilled clinician to join our interdisciplinary team!This position serves the growing community in Northern Colorado in partnership with the current care team.** Utilizing a multidisciplinary approach, the qualified candidate will provide remote support to the Home Care & Hospice team of Advanced Practice Providers. **Position Requirements and Information:** + BC/BE in a relevant specialty + Fellowship training in Hospice & Palliative Medicine - NOT REQUIRED + Experience preferred, new graduates also welcome to apply + Flexible schedule primarily providing back-up coverage for the acting Medical Director **Compensation & Benefits:** + **$140/hr** + Malpractice and Tail Coverage **About the area:** With more than 300 days of sunshine, Northern Colorado is one of the best places to live and work offering spectacular views along the Rocky Mountain Front Range, great weather, endless recreational activities, cultural amenities, education, and professional opportunities. + Within one hour of majestic Rocky Mountain National Park & 90 minutes to world-class ski resorts + Numerous outdoor activities including golf, biking, hiking, camping, rock climbing, hunting, and fishing + Thriving cultural and retail sectors + Highly educated workforce & broad-based business sector leading to substantial growth along the front range + Variety of public and private education options for K-12 and easy access to three major universities **PLEASE SUBMIT YOUR CV TODAY FOR IMMEDIATE CONSIDERATION** As an equal opportunity employer, Banner Health values culture and encourages applications from individuals with varied experiences and backgrounds. Banner Health is an EEO Employer. POS15101 Banner Health complies with applicable federal and state laws and does not discriminate based on race, color, national origin, religion, sex, sexual orientation, gender identity or expression, age, or disability.
$140 hourly 3d ago
Medical Director (NV)
Molina Healthcare 4.4
Columbus, OH jobs
Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. - Participates in and maintains the integrity of the appeals process, both internally and externally. - Responsible for investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams. - Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. - Reviews quality referred issues, focused reviews and recommends corrective actions. - Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. - Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer. - Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process. - Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. - Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures medical protocols and rules of conduct for plan medical personnel are followed. - Develops and implements plan medical policies. - Provides implementation support for quality improvement activities. - Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification. 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$161.9k-315.7k yearly 44d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Cleveland, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare 4.4
Cincinnati, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. **KNOWLEDGE/SKILLS/ABILITIES** Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. + Extract and compile information from various systems to support executive decision-making + Mine and manage information from large data sources. + Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. + Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. + Work with business owners to track key performance indicators of medical interventions + Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives + Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan + Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise + Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management + Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports + Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes + Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making + Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same + Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results + Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare **JOB QUALIFICATIONS** **Required Education** Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field **Required Experience** + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts **Preferred Education** Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. **Preferred Experience** + 3 - 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) + Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. Pay Range: $88,453 - $206,981 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$88.5k-207k yearly 53d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare 4.4
Akron, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. **KNOWLEDGE/SKILLS/ABILITIES** Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. + Extract and compile information from various systems to support executive decision-making + Mine and manage information from large data sources. + Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. + Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. + Work with business owners to track key performance indicators of medical interventions + Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives + Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan + Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise + Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management + Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports + Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes + Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making + Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same + Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results + Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare **JOB QUALIFICATIONS** **Required Education** Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field **Required Experience** + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts **Preferred Education** Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. **Preferred Experience** + 3 - 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) + Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. Pay Range: $88,453 - $206,981 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$88.5k-207k yearly 53d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Akron, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Cincinnati, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Dayton, OH jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare 4.4
Ohio jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. **KNOWLEDGE/SKILLS/ABILITIES** Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. + Extract and compile information from various systems to support executive decision-making + Mine and manage information from large data sources. + Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. + Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. + Work with business owners to track key performance indicators of medical interventions + Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives + Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan + Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise + Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management + Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports + Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes + Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making + Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same + Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results + Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare **JOB QUALIFICATIONS** **Required Education** Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field **Required Experience** + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts **Preferred Education** Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. **Preferred Experience** + 3 - 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) + Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare 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. Pay Range: $88,453 - $206,981 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$88.5k-207k yearly 53d ago
Manager, Medical Economics (New York Health Plan)
Molina Healthcare Inc. 4.4
Ohio jobs
The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities. KNOWLEDGE/SKILLS/ABILITIES Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths. * Extract and compile information from various systems to support executive decision-making * Mine and manage information from large data sources. * Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. * Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions. * Work with business owners to track key performance indicators of medical interventions * Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives * Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan * Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise * Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management * Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports * Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes * Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making * Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same * Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results * Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare JOB QUALIFICATIONS Required Education Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field Required Experience * 3 years management or team leadership experience * 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.) * Strong Knowledge of SQL and PowerBI report development * Familiar with relational database concepts, and SDLC concepts Preferred Education Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field. Preferred Experience * 3 - 5 years supervisory experience * Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans * Experience with Databricks * Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) * Proficiency with Excel and SQL for retrieving specified information from data sources. * Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) * Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form) * Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. • Understanding of value-based risk arrangements * Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare * 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. Pay Range: $88,453 - $206,981 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$88.5k-207k yearly 23d ago
Senior Medical Director
Molina Healthcare 4.4
Cleveland, OH jobs
JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other Health care or management certification. 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$214.1k-417.6k yearly 7d ago
Senior Medical Director
Molina Healthcare 4.4
Dayton, OH jobs
JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other Health care or management certification. 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$214.1k-417.6k yearly 7d ago
Senior Medical Director
Molina Healthcare 4.4
Ohio jobs
JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other Health care or management certification. 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$214.1k-417.6k yearly 7d ago
Medical Director (NV)
Molina Healthcare 4.4
Cleveland, OH jobs
Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. - Participates in and maintains the integrity of the appeals process, both internally and externally. - Responsible for investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams. - Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. - Reviews quality referred issues, focused reviews and recommends corrective actions. - Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. - Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer. - Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process. - Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. - Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures medical protocols and rules of conduct for plan medical personnel are followed. - Develops and implements plan medical policies. - Provides implementation support for quality improvement activities. - Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification. 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$161.9k-315.7k yearly 44d ago
Medical Director, Behavioral Health
Molina Healthcare 4.4
Dayton, OH jobs
Molina's Behavioral Health function provides leadership and guidance for utilization management and case management programs for mental health and chemical dependency services and assists with implementing integrated Behavioral Health care management programs. **Knowledge/Skills/Abilities** Provides Psychiatric leadership for utilization management and case management programs for mental health and chemical dependency services. Works closely with the Regional Medical Directors to standardized utilization management policies and procedures to improve quality outcomes and decrease costs. - Provide regional medical necessity reviews and cross coverage - Standardizes UM practices and quality and financial goals across all LOBs - Responds to BH-related RFP sections and review BH portions of state contracts - Assist the BH MD lead trainers in the development of enterprise-wide teaching on psychiatric diagnoses and treatment - Provides second level BH clinical reviews, BH peer reviews and appeals - Supports BH committees for quality compliance. - Implements clinical practice guidelines and medical necessity review criteria - Tracks all clinical programs for BH quality compliance with NCQA and CMS - Assists with the recruitment and orientation of new Psychiatric MDs - Ensures all BH programs and policies are in line with industry standards and best practices - Assists with new program implementation and supports the health plan in-source BH services - Additional duties as assigned **Job Qualifications** **REQUIRED EDUCATION:** - Doctorate Degree in Medicine (MD or DO) with Board Certification in Psychiatry **REQUIRED EXPERIENCE:** - 2 years previous experience as a Medical Director in clinical practice - 3 years' experience in Utilization/Quality Program Management - 2+ years HMO/Managed Care experience - Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. - Knowledge of applicable state, federal and third-party regulations **Required License, Certification, Association** Active and unrestricted State (TX) Medical License, free of sanctions from Medicaid or Medicare. **Preferred Experience** - Peer Review, medical policy/procedure development, provider contracting experience. - Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. 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. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$161.9k-315.7k yearly 60d+ ago
Medical Director (NV)
Molina Healthcare 4.4
Ohio jobs
Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. - Participates in and maintains the integrity of the appeals process, both internally and externally. - Responsible for investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams. - Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. - Reviews quality referred issues, focused reviews and recommends corrective actions. - Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. - Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer. - Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process. - Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. - Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures medical protocols and rules of conduct for plan medical personnel are followed. - Develops and implements plan medical policies. - Provides implementation support for quality improvement activities. - Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification. 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$161.9k-315.7k yearly 44d ago