Director, Health Plan Operations (Claims) Florida

JOB DESCRIPTION Job Summary

Leads and directs team responsible for the development and administration of state health plan operational functions, programs and services - ensuring functional operations, contractual compliance, and alignment with health plan member satisfaction, retention, quality, and financial goals.

Essential Job Duties

• Under the direction of senior leadership, organizes, plans, staffs, and coordinates health plan operations for market-specific designated lines of business (Medicaid, Medicare, Marketplace, Children''s Health Insurance Program (CHIP), Medicare-Medicaid Plan (MMP), etc.).
• Collaborates with staff and senior leadership to develop and implement provider and member service strategies to improve access and satisfaction for designated health plan(s).
• In conjunction with senior leadership, liaises with corporate operations functions including: claims, configuration information management, provider data management, credentialing, enrollment, and support center operations.
• Oversees claims operations and configuration information management as applicable, and collaborates with corporate business owners and centers of excellence (COEs) to ensure the health plan processes for claims and encounters align with regulatory requirements for each applicable line of business.
• Collaborates with applicable functional COEs to ensure enrollment and support center operations comply with health plan requirements; collaborates with COEs and corporate business owners to mitigate risk related to enrollment processes and support center performance.
• Oversees the plan''s provider network administration activities, specifically ensuring that corporate staff receive data to load correct provider, contract and benefit configuration to support accurate claims payment and accurate provider directories.
• Oversees provider credentialing activities as applicable, and collaborates with the functional COE to ensure compliance with regulatory requirements.
• Oversees the provider issue research and resolution function and the provider claim reconsideration process; coordinates activities and executes strategies to address opportunities to improve provider satisfaction and reduce operational risk in conjunction with provider services.
• Collaborates with the member appeals and grievances (A&G) COE to obtain related analytics, identify trends and execute strategies to improve member satisfaction.
• Supports effective member retention strategies to achieve desired retention goals; also serves as a key partner with community outreach to achieve profitable growth.
• Supports member stakeholder experience team initiatives including: member static website, member web portal and Customer Relationship Management (CRM); ensures compliance with regulatory requirements and successful communication and implementation with members, employees and other key stakeholders to limit operational impact.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of department-specific goals.

Required Qualifications

• At least 8 years of health care operations, health care administration, and/or provider services experience, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Advanced experience with Medicare, Medicaid, and Marketplace plans.
• Experience with prompt pay laws.
• Advanced claims-related experience.
• Demonstrated adaptability and flexibility to change, and to new ideas and approaches.
• Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders.
• Project management experience.
• Excellent verbal and written communication skills.
• Microsoft Office suite proficiency (including Excel), and applicable software programs 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