Kaiser Permanente jobs in Spokane, WA

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. • Facilitates behavioral health-related regional medical necessity reviews and cross coverage. • Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. • Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. • Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. • Provides second level behavioral health clinical reviews, peer reviews and appeals. • Supports behavioral health committees for quality compliance. • Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. • Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). • Assists with the recruitment and orientation of new psychiatric medical directors. • Ensures all behavioral health programs and policies are in line with industry standards and best practices. • Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications • At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. • Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. • Board Certification in Psychiatry. • 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. #PJHS #LI-AC1 #HTF 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: $186,201.39 - $363,092.71 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The Provider Claims Adjudicator is responsible for responding to providers regarding issues with claims, coordinating, investigates and confirms the appropriate resolution of claims issues. This role will require actively researching issues to adjudicate claims Requires knowledge of operational areas and systems. **Knowledge/Skills/Abilities** + Facilitates the resolution of claims issues, including incorrectly paid claims, by working with operational areas and provider billings and analyzing the systems. + This role is involved in member enrollment, provider information management, benefits configuration and/or claims processing. + Responds to incoming calls from providers regarding claims inquiries and provides excellent customer service; documents calls and interactions. + Assists in the reviews of state or federal complaints related to claims. + Supports the other team members with several internal departments to determine appropriate resolution of issues. + Researches tracers, adjustments, and re-submissions of claims. + Adjudicates or re-adjudicates high volume of claims in a timely manner to ensure compliance to departmental turn-around time and quality standards. + Manages defect reduction by supporting the identifying and communicating error issues and potential solutions to management. + Handles special projects as assigned. + Other duties as assigned. Knowledgeable in systems utilized: + QNXT + Pega + Verint + Kronos + Microsoft Teams + Video Conferencing + Others as required by line of business or state **Job Function** Provides customer support and stellar service to assist Molina providers with claims inquiries. Leads and resolves issues and addresses needs appropriately and effectively, while demonstrating Molina values in their actions. Responsible for effectively managing and documenting calls and responding to providers regarding issues with claims and inquiries. Handles escalated inquiries, complex provider claims payments, records, and provides counsel to providers. Helps to mentor and coach Provider Claims Adjudicators. **Job Qualifications** **REQUIRED EDUCATION:** Associate's Degree or equivalent combination of education and experience; **REQUIRED EXPERIENCE:** 2-3 years customer service, claims, provider and investigation/research experience. Outcome focused and knowledge of multiple systems. 1+ years of claims research and/or issue resolution or analysis of reimbursement methodologies within the managed care health care industry **PREFERRED EDUCATION:** Bachelor's Degree or equivalent combination of education and experience **PREFERRED EXPERIENCE:** 4 years **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in a home or office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. 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: $21.16 - $38.37 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The Director, Clinical Data Acquisition for Risk Adjustment, is responsible for the implementation, monitoring, and oversight of all chart collection for Risk Adjustment, RADV, or Risk Adjustment-like projects, and other state specific audit projects and deliverables related to accurate billing and coding. This role also works with the Health Plan Risk/Quality leaders to strategically plan for supplemental data source (SDS) acquisition from providers as well as Electronic Medical Record (EMR) access. This position oversees management of training for all CDA team members as well as company Risk Adjustment retrieval and data completeness training, onboarding for CDA team members, vendor management for chart collection vendors, Supplemental data, and chart collection research. **Job Duties** + Plans and/or implements operational processes for Risk Adjustment operations that meet state and federal reporting requirements/rules and are aligned with effective practices as identified in the healthcare quality improvement literature and within Molina plans. + Develops and implements targeted collection of clinical data acquisition related to performance reporting and improvement, including member and provider outreach. + Serves as operations subject matter expert and lead for Molina Risk Adjustment, using a defined roadmap, timeline and key performance indicators. + Collaborates with the national intervention collaborative analytics and strategic teams to deliver value for both prospective and retrospective risk programs. + Communicates with the Molina Plan Senior Leadership Team, including the Plan President, Chief Medical Officer, national Risk Adjustment teams and strategic teams about key deliverables, timelines, barriers and escalated issues that need immediate attention. + Presents concise summaries, key takeaways and action steps about Molina Risk Adjustment processes, strategy and progress to national, regional and plan meetings. + Demonstrates ability to lead and influence cross-functional teams that oversee implementation of Risk Adjustment projects. + Possesses a strong knowledge in Risk Adjustment and RADV to implement effective operations that drive change. + Functions as key lead for clinical chart review/abstraction and team management. This includes qualitative analysis, reporting and development of program materials, templates or policies. Maintains productivity reporting, management and coaching. + Maintains advanced ability to collaborate and Manage production vendor relationships, including oversight, data driven KPI measurement and performance mitigation strategies. **Job Qualifications** **REQUIRED EDUCATION:** Bachelor's Degree in a clinical field, Public Health, Healthcare, or equivalent. **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** - 8+ years' experience in managed healthcare, including at least 4 years in health plan Risk Adjustment or clinical data acquisition/chart retrieval roles - Operational knowledge and experience with Excel and Visio (flow chart equivalent). **PREFERRED EXPERIENCE:** - 10+ years' experience with member/ provider (Risk Adjustment) outreach and/or clinical intervention or improvement studies (development, implementation, evaluation) - 3-5 years Supervisory experience. - Project management and team building experience. - Experience developing performance measures that support business objectives. **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** - Certified Professional in Health Quality (CPHQ) - Nursing License (RN may be preferred for specific roles) - Certified Risk Adjustment Coder (CRC) 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: $107,028 - $250,446 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and supervises a team supporting non-clinical healthcare services activities for care management, care review, utilization management, transitions of care, behavioral health, long-term services and supports (LTSS), and/or other program specific service support - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Supervises healthcare services operations support team members within Molina's clinical/healthcare services function, which may include care review, care management, and/or correspondence processing, etc. - Researches and analyzes the workflow of the department, and offers suggestions for improvement and/or changes to leadership; assists with the implementation of changes. - Conducts employee and team productivity/quality assurance checks and documents results for accuracy and time compliance. - Provides regular verbal and written feedback to staff regarding performance and opportunities for improvement. - Assists in the development and implementation of internal desktop processes and procedures. - Establishes and maintains positive and effective work relationships with coworkers, clients, members, providers, and customers. Required Qualifications- At least 5 years of operations or administrative experience in health care, preferably within a managed care setting, or equivalent combination of relevant education and experience. - Strong analytic and problem-solving abilities. - Strong organizational and time-management skills. - Ability to multi-task and meet project deadlines. - Attention to detail. - Ability to build relationships and collaborate cross-functionally. - Excellent verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Supervisory/leadership experience. 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: $77,969 - $106,214 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. **Job Duties** This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. - Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. - Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. - Forwards requested information/documentation to prospective providers in a timely manner. - Maintains database of all contracts and specific applications sent to prospective new providers. - Completes and updates Provider Information Forms for each new contract. - Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. - Sends out new provider welcome packets to providers who have contracted with the plan. - Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. - Formats and distributes Provider network resources (e.g. electronic specialist directory). **Job Qualifications** **REQUIRED EDUCATION** : High School Diploma or equivalent GED **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES** : 1 year customer service, provider service, contracting or claims experience in the healthcare industry. **PREFERRED EDUCATION** : Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience **PREFERRED EXPERIENCE** : Managed Care experience To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.16 - $42.2 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion. Plans and directs schedules as well as project budgets. Monitors the project from inception through delivery. May engage and oversee the work of external vendors. Assigns, directs and monitors system analysis and program staff. These positions' primary focus is project/program management. **Job Duties** + Active collaborator with people who are responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion. + Plans and directs schedules as well as project budgets. + Monitors the project from inception through delivery. + May engage and oversee the work of external vendors. + Focuses on process improvement, organizational change management, program management and other processes relative to the business. + Leads and manages team in planning and executing business programs. + Serves as the subject matter expert in the functional area and leads programs to meet critical needs. + Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements. Delivers the appropriate artifacts as needed. + Works with operational leaders within the business to provide recommendations on opportunities for process improvements. + Creates business requirements documents, test plans, requirements traceability matrix, user training materials and other related documentations. + Generate and distribute standard reports on schedule **JOB QUALIFICATIONS** **REQUIRED EDUCATION** : Bachelor's Degree or equivalent combination of education and experience. **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES** : + 3-5 years of Program and/or Project management experience. + Operational Process Improvement experience. + Healthcare experience. + Experience with Microsoft Project and Visio. + Excellent presentation and communication skills. + Experience partnering with different levels of leadership across the organization. **PREFERRED EDUCATION** : Graduate Degree or equivalent combination of education and experience. **PREFERRED EXPERIENCE** : - 5-7 years of Program and/or Project management experience. - Managed Care experience. - Experience working in a cross functional highly matrixed organization. **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION** : - PMP, Six Sigma Green Belt, Six Sigma Black Belt Certification and/or comparable coursework desired. 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: $77,969 - $155,508 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides entry level analyst support for clinical information systems activities. Responsible for provision of application technical support and design for clinical information systems - ensuring creation of workflows and enhancements that support process improvement and change management initiatives. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Assists in the development and support of clinical, practice management and operational workflows. - Assists in the design of workflow analysis, device integration, planning and implementation of clinical systems. - Participates in the system implementation life cycle including: planning, implementation, training, and post-implementation support. - Assists in issue resolution related to the clinical information system. Required Qualifications - At least 1 year of system implementation experience, or equivalent combination of relevant education and experience. - Knowledge of systems design methods and techniques. - Knowledge base in health care informatics. - Ability to work independently, within a team and collaboratively across teams. - Analysis, synthesis and problem-solving skills. - Attention to detail and accuracy. - Multi-tasking, planning, and workload prioritization skills. - Verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. 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: $21.16 - $42.2 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides senior level support for accurate and timely intake and interpretation of regulatory and/or functional requirements related to but not limited to coverage, reimbursement, and processing functions to support systems solutions development and maintenance. This role includes coordination with stakeholders and subject matter experts on partnering teams and supporting governance committees where applicable. **JOB DUTIES** + Develops and maintains requirement documents related to coverage, reimbursement and other applicable system changes in areas to ensure alignment to regulatory baseline requirements and any health plan/product team developed requirements. + Monitors regulatory sources to ensure all updates are aligned as well as work with operational leaders within the business to provide recommendations for process improvements and opportunities for cost savings. + Leads coordinated development and ongoing management /interpretation review process, committee structure and timing with key partner organizations. Interpret customer business needs and translate them into application and operational requirements. + Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices. + Where applicable, codifies the requirements for system configuration alignment and interpretation. + Provides support for requirement interpretation inconsistencies and complaints. + Assists with the development of requirement solution standards and best practices while suggesting improvement processes to consistently apply requirements across states and products where possible. + Self-organized reporting to ensure health plans/product team and other leadership are aware of work efforts and impact for any prospective or retrospective requirement changes that can impact financials. + Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product. + Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes. **Recoveries & Disputes** + Review and validate provider complaints and payment disputes, ensuring accurate and timely resolution in line with policy and contractual guidelines. + Partner with provider relations, Health plans and appeals teams to address recurring dispute trends and recommend systemic solutions. + Evaluate root cause for the disputes and recommend improvements to reduce claim errors and prevent improper payments. + Provide actionable insights and recommendations to leadership to drive continuous improvement. **Skills & Competencies** + Proven experience handling provider disputes, appeals, and overpayment recoveries in a managed care or payer environment. + In-depth knowledge of medical and hospital claims processing, including CPT/HCPCS, ICD, and modifier usage. + Strong understanding of claim system configurations, payment policies, and audit processes. + Exceptional analytical, problem-solving, and documentation skills. + Ability to translate complex business problems into clear system requirements and process improvements. + Proficiency in Excel + Knowledge in QNXT preferred + Strong communication and stakeholder management skills with ability to influence across teams. **KNOWLEDGE/SKILLS/ABILITIES** + Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation are agreed on and clear for solutioning. + Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas. + Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company. + Ability to concisely synthesize large and complex requirements. + Ability to organize and maintain regulatory data including real-time policy changes. + Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems. + Ability to work independently in a remote environment. + Ability to work with those in other time zones than your own. **JOB QUALIFICATIONS** **Required Qualifications** + At least 4 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience. + Policy/government legislative review knowledge + Strong analytical and problem-solving skills + Familiarity with administration systems + Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams + Previous success in a dynamic and autonomous work environment **Preferred Qualifications** + Project implementation experience + Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA). + Medical Coding 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: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. 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: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides senior level audit support for delegation oversight activities. Responsible for ensuring delegates are complaint with the applicable state, federal, contractual requirements, National Committee for Quality Assurance (NCQA), and Molina requirements for the health plan(s) they support. Identifies risk and non-compliance, issues corrective action, and actively manages the corrective action process to completion reducing and managing Molina's risk. Essential Job Duties * Leads and performs pre-delegation, annual audits, and ensures all components of audit activities comply with contractual, regulatory, and accreditation requirements. * Conducts detailed and focused audits on delegates' policies, procedures, case files and evidence of ongoing monitoring to ensure quality and cost-effective provision of delegated services. * Engages delegate leadership to educate, collaborate, and/or remediate risks to Molina. * Leverages highly skilled analytical insights and experience to identify delegate systemic issues and risks that impact the business; collaborates with health plans and/or corporate departments and other business owners to actively address and mitigate risk to Molina. * Conducts analysis of audit issues to identify root-causes, develops and issues corrective action plans (CAPs), and documents follow-up to ensure successful remediation. * Prepares, tracks and provides audit finding reports in accordance with departmental requirements. * Prepares, submits and presents audit reports to delegation oversight committees. * Presents audit findings to delegates, and makes recommendations for improvements based on audit results. * Collaborates with delegation oversight leadership to develop and maintain assessment tools. * Makes independent decisions on complex issues and project components. * Serves as subject matter expert on policies, regulations, contractual requirements and delegate contracts for the relevant area. * Remains current on applicable regulatory, contractual and accreditation requirements and standards; interprets regulatory, contractual and accreditation changes and assesses their impact on the relevant area. * Conducts outreach to multiple department heads regarding key performance indicator (KPI) data analysis for quarterly meetings. * Provides training and support to new and existing delegation oversight team members. Required Qualifications * At least 3 years of managed care experience, including at least 2 years of delegation oversight auditing experience, or equivalent combination of relevant education and experience. experience. * Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required. * Ability to collaborate cross-functionally across a highly matrixed organization. * Strong attention to detail and organizational skills. * Strong critical-thinking, and problem-solving/analytical abilities. * Strong interpersonal and verbal/written communication skills. * Microsoft Office suite proficiency (including Excel), and ability to learn/navigate new software programs. Preferred Qualifications * Certified Credentialing Specialist (CCS), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), Certified Clinical Coder (CCD), Certified Medical Audit Specialists (CMAS), Certified Professional in Healthcare Management (CPHM) and/or other health care certification/licensure. If licensed, license must be active and unrestricted in state of practice. 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: $77,969 - $128,519 / 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.

This position will be responsible for supporting the execution of merger and acquisition transactions and will actively contribute in advancing Molina Healthcare's overall growth strategy. The role entails working closely with the senior members of the Corporate Development team and will actively interact with the business leaders and senior management team at Molina. The ideal candidate will have at least two years of experience as an analyst at an investment bank or similar firm. **Knowledge/Skills/Abilities** - Develop financial models and perform analyses to assess potential acquisition, joint venture and other business development opportunities (i.e., discounted cash flow, internal rate of return and accretion/dilution) - Prepare ad-hoc analyses and presentations to help facilitate various discussions - Research and analyze industry trends, competitive landscape and potential target companies - Coordinate deal activities among internal cross-functional teams and external parties - Coordinate due diligence and closing-related activities - Actively participate in reviewing and negotiating transaction agreements - Prepare board and senior management presentations **Job Qualifications** **REQUIRED EDUCATION:** Bachelor's degree in Accounting or Finance or related fields **REQUIRED EXPERIENCE:** + Minimum 5 years' experience in financial modeling and analysis + Ability to synthesize complex ideas and translate into actionable information + Strong analytical and modeling skills + Excellent verbal and written communication skills + Highly collaborative and team-oriented with a positive, can-do attitude + Ability to multi-task, set priorities and adhere to deadlines in a high-paced organization **PREFERRED EXPERIENCE:** + Prior analyst experience in investment banking strongly preferred + Healthcare industry experience preferred **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. 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: $80,412 - $156,803 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides customer service support for inbound/outbound pharmacy calls from members, providers, and pharmacies. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties - Handles and records inbound/outbound pharmacy calls from members, providers and pharmacies in accordance with departmental policies, state regulations, National Committee of Quality Assurance (NCQA) guidelines, and Centers for Medicare and Medicaid Services (CMS) standards. - Provides coordination and processing of pharmacy prior authorization requests and/or appeals. - Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other necessary information to providers, members and pharmacies. - Assists with clerical tasks and other day-to-day pharmacy call center operations as delegated. - Effectively communicates plan benefit information, including but not limited to: formulary information, copay amounts, pharmacy location services and prior authorization outcomes. - Assists members and providers with initiating verbal and written coverage determinations and appeals. - Records calls accurately within the pharmacy call tracking system. - Maintains established pharmacy call quality and quantity standards. - Interacts with appropriate primary care providers to ensure member registry is current and accurate. - Supports pharmacists with completion of comprehensive medication reviews (CMRs)through pre-work up to case preparation. - Proactively identifies ways to improve pharmacy call center member relations. Required Qualifications - At least 1 year related experience, including call center or customer service experience, or equivalent combination of relevant education and experience. - Excellent customer service skills. - Ability to work independently when assigned special projects, such as pill box requests, case management referrals, over the counter (OTC) requests, etc. - Ability to multi-task applications while speaking with members. - Ability to multi-task applications while speaking with members. - Ability to develop and maintain positive and effective work relationships with coworkers, clients, members, providers, regulatory agencies, and vendors. - Ability to meet established deadlines. - Ability to function independently and manage multiple projects. - Excellent verbal and written communication skills, including excellent phone etiquette. - Microsoft Office suite (including Excel), and applicable software program(s) proficiency. Preferred Qualifications - Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. - Health care industry experience. 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: $21.16 - $28.82 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

We are seeking a Senior AI Developer/Engineer to lead the design and deployment of intelligent conversational agents across IT, HR, and enterprise platforms. 1. Develop and implement AI-driven virtual assistants using Moveworks, Oracle GenAI Agents, and Microsoft Azure AI Copilot. 2. Design conversational flows, intents, and memory for multi-turn interactions. 3. Integrate AI agents with enterprise systems like ServiceNow, Oracle HCM, and Microsoft Teams. 4. Create custom agent workflows and automation using APIs and low-code tools. 5. Apply prompt engineering and fine-tune LLMs to ensure accuracy and tone alignment. 6. Implement testing frameworks, QA processes, and user acceptance validation. 7. Manage deployments, monitor performance, and ensure secure data handling. 8. Continuously enhance AI agent capabilities using platform updates and analytics insights. 9. Document architectures, workflows, and operational procedures. 10. Ensure compliance with AI governance, data privacy, and responsible AI principles. 11. Collaborate with cross-functional teams across IT, HR, and AI governance committees. 12. Mentor developers and promote best practices in AI development. 13. Stay current with new Moveworks and Azure AI features for enterprise automation. 14. Strong skills in Python, REST APIs, OAuth 2.0, and enterprise integrations required. 15. Ideal candidate has experience with LLMs, chatbots, and secure cloud AI deployment. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** Bachelor's Degree in Business Administration or Information Technology or equivalent combination of education and experience **REQUIRED EXPERIENCE:** 5-7 years related experience in a combination of applicable business and business systems **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** **PREFERRED EDUCATION:** **PREFERRED EXPERIENCE:** **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** **STATE SPECIFIC REQUIREMENTS:** 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: $77,969 - $117,000 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to financial and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of Value Based Contracts (VBCs) post execution, including but not limited to, data analysis and reporting that ensures VBCs fulfill APM provider payment and regulatory requirements related to state-mandated value-based programs. Supports Manager with contracting/re-contracting of VBCs, issue escalations and JOCs on exception. Synchronizes data among multiple systems when applicable and ensures adherence to business and system requirements of customers as it pertains to contracting and network management. **Job Duties** This role supports assigned contracts with VBC providers that result in high quality and cost-effective care. Maintains tracking system and publishes reports according to departmental procedures. Contracting/re-contracting of VBCs, issue escalations and Joint Operating Committees on exception. - Assists Manager and/or Director in the negotiation of medical group/IPA and hospital VBC contracting. - Serves as VBC regulatory data and reporting lead by developing and producing as required to engage with provider and facilitate VBC performance. - Supports VBC network throughout the state to include onboarding VBC providers and supporting JOC's. - Clearly and professionally communicates VBC contract terms to VBC providers. - Coordinates preparation and routing distribution of documents to complete the contracting process in a timely and thorough manner according to standardized processes. - Communicates proactively with other departments to ensure effective and efficient business results. - Trains and monitors newly hired Contract Specialist(s). - Participates in other VBC related special projects as directed. - Limited team travel once to twice annually. **Job Qualifications** **REQUIRED EDUCATION:** Bachelor's Degree or equivalent work experience in health care field including, but not limited to, provider's office, managed care, or other health care field. **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** - 4-6 years' previous experience in contracting with large specialty or multispecialty provider groups. - 1-3 Years Managed Care experience **PREFERRED EXPERIENCE** : Provider facing experience and knowledge of integrated delivery systems, hospitals and groups (specialty and ancillary) highly desirable. Experience generating financial reporting to meet regulatory requirements. Ohio based candidate desired; however, not required. Pay Range: $30.37 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and supervises a team supporting non-clinical healthcare services activities for care management, care review, utilization management, transitions of care, behavioral health, long-term services and supports (LTSS), and/or other program specific service support - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties * Supervises healthcare services operations support team members within Molina's clinical/healthcare services function, which may include care review, care management, and/or correspondence processing, etc. * Researches and analyzes the workflow of the department, and offers suggestions for improvement and/or changes to leadership; assists with the implementation of changes. * Conducts employee and team productivity/quality assurance checks and documents results for accuracy and time compliance. * Provides regular verbal and written feedback to staff regarding performance and opportunities for improvement. * Assists in the development and implementation of internal desktop processes and procedures. * Establishes and maintains positive and effective work relationships with coworkers, clients, members, providers, and customers. Required Qualifications• At least 5 years of operations or administrative experience in health care, preferably within a managed care setting, or equivalent combination of relevant education and experience. * Strong analytic and problem-solving abilities. * Strong organizational and time-management skills. * Ability to multi-task and meet project deadlines. * Attention to detail. * Ability to build relationships and collaborate cross-functionally. * Excellent verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Supervisory/leadership experience. 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: $77,969 - $106,214 / 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.

Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care experience To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.16 - $42.2 / HOURLY * 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.

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.

The Director, Clinical Data Acquisition for Risk Adjustment, is responsible for the implementation, monitoring, and oversight of all chart collection for Risk Adjustment, RADV, or Risk Adjustment-like projects, and other state specific audit projects and deliverables related to accurate billing and coding. This role also works with the Health Plan Risk/Quality leaders to strategically plan for supplemental data source (SDS) acquisition from providers as well as Electronic Medical Record (EMR) access. This position oversees management of training for all CDA team members as well as company Risk Adjustment retrieval and data completeness training, onboarding for CDA team members, vendor management for chart collection vendors, Supplemental data, and chart collection research. Job Duties * Plans and/or implements operational processes for Risk Adjustment operations that meet state and federal reporting requirements/rules and are aligned with effective practices as identified in the healthcare quality improvement literature and within Molina plans. * Develops and implements targeted collection of clinical data acquisition related to performance reporting and improvement, including member and provider outreach. * Serves as operations subject matter expert and lead for Molina Risk Adjustment, using a defined roadmap, timeline and key performance indicators. * Collaborates with the national intervention collaborative analytics and strategic teams to deliver value for both prospective and retrospective risk programs. * Communicates with the Molina Plan Senior Leadership Team, including the Plan President, Chief Medical Officer, national Risk Adjustment teams and strategic teams about key deliverables, timelines, barriers and escalated issues that need immediate attention. * Presents concise summaries, key takeaways and action steps about Molina Risk Adjustment processes, strategy and progress to national, regional and plan meetings. * Demonstrates ability to lead and influence cross-functional teams that oversee implementation of Risk Adjustment projects. * Possesses a strong knowledge in Risk Adjustment and RADV to implement effective operations that drive change. * Functions as key lead for clinical chart review/abstraction and team management. This includes qualitative analysis, reporting and development of program materials, templates or policies. Maintains productivity reporting, management and coaching. * Maintains advanced ability to collaborate and Manage production vendor relationships, including oversight, data driven KPI measurement and performance mitigation strategies. Job Qualifications REQUIRED EDUCATION: Bachelor's Degree in a clinical field, Public Health, Healthcare, or equivalent. REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: * 8+ years' experience in managed healthcare, including at least 4 years in health plan Risk Adjustment or clinical data acquisition/chart retrieval roles * Operational knowledge and experience with Excel and Visio (flow chart equivalent). PREFERRED EXPERIENCE: * 10+ years' experience with member/ provider (Risk Adjustment) outreach and/or clinical intervention or improvement studies (development, implementation, evaluation) * 3-5 years Supervisory experience. * Project management and team building experience. * Experience developing performance measures that support business objectives. PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: * Certified Professional in Health Quality (CPHQ) * Nursing License (RN may be preferred for specific roles) * Certified Risk Adjustment Coder (CRC) 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: $107,028 - $250,446 / 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.

The Clinical Lab Assistant performs the pre-analytic phases of laboratory testing procedures and may also perform the analytic and post analytic phases of waived testing procedures. Duties include face to face and telephone customer service; computer data entry and retrieval, workplace cleanliness and maintenance. S/he is responsible for documentation of all activities, monitoring supplies, and compliance with all regulatory and accreditation requirements related to safety and lab testing. Responsible for following GH Laboratory policies and procedures. Essential Responsibilities: * Specimen Collection and Processing: Collects specimens for lab testing. Has knowledge of special specimen collection and handling requirements for specific populations, eg. infants, pediatric and geriatric patients. Processes specimens for lab testing according to laboratory procedures. * Computer Data Entry and Retrival: Accessions specimens, retrieves information, enters results. * Other duties: Participates in Performance Improvement activities. Performs maintenance. Performs waived testing, EKG testing. Teaches phlebotomy students, employees. * Technical Resource: Helps resolve problems and answer pre-analytical procedural questions. Serves as a frontline resource to laboratory customers. Assists in the review and updates of laboratory procedure manuals.