Molina Healthcare Nursing Jobs

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Recent Jobs

Pediatric

Full-time

3 days ago

Care Manager (RN) - King County/Peds

Molina Healthcare Bothell, WA

JOB DESCRIPTION Hybrid role with approximately 10% local travel within King County . Candidates should have care management experience in Pediatrics, NICU, or Private Duty Nursing , with responsibility for managing a caseload of 30-35 members. Prior experience working remotely in a care management or clinical setting is required, along with the ability to independently coordinate care, manage complex cases, and support positive outcomes for pediatric populations. Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). 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 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Utilization Review

Full-time

3 days ago

Medical Review Nurse (RN)

Molina Healthcare Columbus, OH

Job Summary Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Job Duties • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. • Identifies and reports quality of care issues. • Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. • Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. • Supplies criteria supporting all recommendations for denial or modification of payment decisions. • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. • Provides training and support to clinical peers. • Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: • At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact license is acceptable where states allow. • Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and • Healthcare Common Procedure Coding (HCPC). • Experience working within applicable state, federal, and third-party regulations. • Analytic, problem-solving, and decision-making skills. • Organizational and time-management skills. • Attention to detail. • Critical-thinking and active listening skills. • Common look proficiency. • Effective verbal and written communication skills. • Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: • Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. • Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. • Billing and coding 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: $29.05 - $56.64 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Nurse Manager Healthcare Services - San Diego, CA

Molina Healthcare Long Beach, CA

$84,067 - $163,931 / year

JOB DESCRIPTION Candidates must hold a current California license , reside in the San Diego, California area , and be able to travel up to 10% as required. The ideal candidate will have 2 to 3 years of leadership experience within a managed care organization , with a proven ability to lead teams, drive performance, and support member-centered care initiatives. Strong leadership, collaboration, and operational management skills are essential to successfully advance care delivery goals and improve member outcomes. The successful candidate will ensure members achieve optimal health outcomes through the integrated delivery and coordination of care across the continuum while contributing to organizational strategies that promote high-quality, cost-effective care. Job Summary Leads and manages a multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Oversees team performance for one or more of the following healthcare services functions: care management, utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), transition of care, behavioral health, long-term services and supports (LTSS), and/or special programs. • Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model. • Functions as a “hands-on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery. • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. • Assists in implementing care management, utilization management, behavioral health, care transitions, LTSS and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence. • Ensures high-risk, complex members are adequately supported. • Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services. • Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care. • Oversees interdisciplinary care team (ICT) meetings. • Analyzes and reports on care access and monitoring statistics including plan utilization, staff productivity, cost-effective utilization of services, management of targeted member population, and triage activities. • Ensures completion of staff quality audit reviews evaluates services provided, outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost-effectiveness and compliance with all state and federal regulations and guidelines. • Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate. • Identifies opportunities for care delivery/quality/operational/etc. process improvements. • Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 7 years of health care experience, including at least 3 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience. • At least 1 year of management/leadership experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Strong customer service skills/member-centric focus. • Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations. • Ability to prioritize and manage multiple deadlines. • Strong organizational and problem-solving skills. • Ability to collaborate cross-functionally within a highly matrixed organization. • Strong written and verbal communication skills. • Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications • Clinical experience. • Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population 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: $84,067 - $163,931 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Telehealth

Full-time

4 days ago

(RN) Remote Care Manager - Medicare STARS/Quality (MI Based)

Molina Healthcare Detroit, MI

$26.41 - $51.49 / hour

JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Experience closing care gaps (HEDIS measures, medication adherence, HOS surveys). • Comfort using care management platforms and population health tools. • Track record of successful member engagement and outreach. • Understanding of CMS Star Ratings methodology and quality bonus payments. 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 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Telehealth

Full-time

6 days ago

Care Manager (RN)

Molina Healthcare Seattle, WA

$30.37 - $59.21 / hour

JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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