Program Manager, Healthcare Services (Utilization Management)
Role summary
This remote Program Manager role in Healthcare Services focuses on Utilization Management. The position provides subject matter expertise and leadership for healthcare services functions, including project/program design, execution, and evaluation, ensuring compliance with standards and contractual commitments. The role contributes to strategies for quality and cost-effective member care. Key duties involve planning and executing internal projects, analyzing utilization management data, driving process improvements, and collaborating with customers to define functional requirements. The role also includes conducting quality audits and creating business documentation like BRDs and test plans, with potential use of AI for reporting.
\*\*\*Remote and must live in the United States\*\*\*
JOB DESCRIPTION
Job Summary
Provides subject matter expertise and leadership to healthcare services function - providing support for project/program/process design, execution, evaluation and support, and ensuring compliance with regulatory and internal standards, practices, policies and contractual commitments. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- Collaboratively plans and executes internal healthcare services projects and programs involving department or cross-functional teams of subject matter experts - delivering products from the design process to completion.
- Provides ongoing communication related to program goals, evaluation and support to ensure compliance with standardized protocols and processes.
- May engage and oversee the work of external vendors.
- Utilization Management data analysis.
- Focuses on process improvement, organizational change management, program management and other processes relative to business needs.
- Serves as a subject matter expert and leads healthcare services programs to meet critical needs.
- Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements.
- Conducts quality audits to assess healthcare services staff educational needs and service quality, and implements quality initiatives within the department as appropriate.
- Creates business requirements documents (BRDs), test plans, requirements traceability matrix (RTMs), user training materials and other related business documents.
- Potential to utilize AI for reporting.
Required Qualifications
- At least 5 years of health care experience, including experience in clinical operations, and at least 3 or more years in one or more of the following areas: utilization management, care management, care transitions, behavioral health, or equivalent combination of relevant education and experience.
- Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Advanced Practice Social Worker (APSW), Certified Health Education Specialist (CHES), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC) or Licensed Marriage and Family Therapist (LMFT). 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 analytical and problem-solving skills.
- Strong organizational and time-management skills.
- Ability to work in a cross-functional, professional environment.
- Experience working within applicable state, federal, and third-party regulations.
- 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), Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care or management certification.
- Leadership experience.
- 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: $65,791.66 - $142,548.59 / ANNUAL
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.