Provides executive-level strategy and leadership for member and provider support center operations to optimize performance and satisfaction. Manages workforce, quality assurance, and vendor performance across multiple lines of business while ensuring regulatory compliance and financial goals.
The auditor is responsible for evaluating adherence to regulatory requirements and internal policies to identify compliance gaps. They also provide comprehensive advice to departments regarding compliance risks and support annual risk assessment processes.
The pharmacy technician will review and process non-formulary and prior authorization requests while ensuring compliance with pharmacy policies. They will also assist providers and members with prescription claims and pharmacy service access issues.
The Senior Analyst supports the out-of-network provider liability model by developing analytics, reporting, and market intelligence to inform negotiation strategies and dispute outcomes. They are responsible for integrating complex datasets, building dashboards, and translating financial data into actionable insights for leadership.
The Care Manager coordinates long-term services and supports for members, developing and monitoring individualized care plans to ensure quality outcomes. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and provide ongoing support to address medical and psychosocial needs.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired health outcomes.
The Care Manager coordinates long-term services and supports for members, including conducting comprehensive assessments and developing individualized care plans. They facilitate interdisciplinary team meetings and monitor member progress to ensure quality, cost-effective care delivery.
The Care Manager coordinates long-term services and supports for members, including conducting comprehensive assessments and developing individualized care plans. They facilitate interdisciplinary care team meetings and monitor member progress to ensure quality and cost-effective care delivery.
The Care Manager coordinates long-term services and supports for members, developing and monitoring individualized care plans to ensure quality outcomes. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and provide ongoing support to address medical and psychosocial needs.
The Senior Accountant provides senior-level accounting support including month-end close, account reconciliations, and financial statement preparation. They ensure compliance with GAAP and Statutory Accounting Principles while collaborating with interdepartmental partners to validate financial reporting accuracy.
The role involves designing and deploying advanced machine learning models and AI solutions to derive insights from large datasets. Responsibilities also include implementing agentic workflows and retrieval-augmented generation patterns to enhance operational efficiency and model performance.
Provides strategy and leadership for the medical economics team to identify risks, improve financial performance, and support clinical program initiatives. Oversees the development of scoreable action item tracking tools and collaborates with health plans to optimize data management and performance.
The clinician is responsible for verifying the medical necessity of behavioral health services and ensuring compliance with clinical guidelines and insurance policies. They collaborate with multidisciplinary teams and providers to manage treatment plans and support member outcomes.
The Senior Analyst provides analytical support by extracting and synthesizing complex healthcare data to identify medical cost drivers and utilization trends. They collaborate with cross-functional teams to develop actionable insights, monitor performance, and recommend cost-containment strategies.
The Community Connector serves as a local advocate to assist vulnerable members in managing their health care needs and navigating health plan benefits. They perform field-based duties such as home visits, coordinating social services, and conducting outreach to disconnected members.
The Senior Analyst provides senior-level analytical support by extracting and synthesizing complex healthcare data to identify cost and utilization trends. They are responsible for developing actionable insights and affordability initiatives that enhance financial performance and support strategic decision-making.
The Care Manager supports Medicaid members by conducting assessments, developing care plans, and facilitating interdisciplinary team meetings. They perform both telephonic outreach and in-person home visits to monitor member progress and ensure quality, cost-effective care.
Leads and directs the Strategic and Clinical Analytics team to translate complex healthcare data into actionable insights for clinical and operational decision-making. Designs and conducts program evaluations to assess clinical outcomes, ROI, and performance metrics while mentoring staff.
Provides non-clinical administrative support to the care management team, including case assignment, member screening, and scheduling. Facilitates communication and processes correspondence to ensure effective delivery of member care services.
Provides peer support services for members with behavioral health and chemical dependency needs while acting as a member advocate. Collaborates with multidisciplinary teams to assist members in setting and achieving recovery goals.
The analyst investigates and resolves provider appeals by reviewing medical records and claim history to ensure billing accuracy. They communicate determinations to providers and collaborate with internal departments to track coding errors and maintain compliance.
The analyst is responsible for the intake and interpretation of regulatory requirements to support system solutions and maintenance. They also coordinate with stakeholders to ensure alignment, manage requirement documentation, and apply automation tools to improve operational efficiency.
The Executive Assistant provides comprehensive administrative support to an executive and their division, including managing calendars, travel, and correspondence. They are responsible for preparing reports, conducting research, and serving as a recording secretary for committee meetings.
The Care Manager coordinates integrated care for Medicaid members by conducting assessments, developing care plans, and facilitating interdisciplinary team meetings. They perform both telephonic outreach and in-person home visits to monitor member progress and address health barriers.
Leads and directs the configuration team responsible for the delivery, execution, and maintenance of technical products supporting enterprise operations. Acts as the primary bridge between business stakeholders and technical delivery teams to ensure solutions align with business outcomes and regulatory requirements.
The Care Manager coordinates integrated delivery of care for high-need members by developing and monitoring personalized care plans. They facilitate interdisciplinary team meetings and conduct comprehensive assessments to ensure quality and cost-effective service delivery.
The specialist is responsible for the accurate validation and maintenance of provider information within claims and network databases. They also perform audits on provider records to ensure quality and financial accuracy while supporting network administration projects.
Review and process prior authorization requests for pharmacy services while ensuring compliance with established policies. Assist providers and members with prescription claims and pharmacy service access issues to optimize medication-related health outcomes.
Leads and manages a team responsible for pharmacy operations and Pharmacy Benefit Management (PBM) activities, including oversight of delegated services and product implementation. Collaborates with cross-functional partners to optimize medication-related health outcomes and ensures compliance with state and federal regulations.
The Senior Representative serves as the primary point of contact for contracted providers, managing network adequacy, provider education, and issue resolution. They are responsible for ensuring provider compliance with Molina policies and facilitating coordination between the health plan and complex provider communities.
The investigator will re-evaluate medical claims and records to identify and resolve instances of fraud, waste, and abuse. They will manage caseloads, ensure regulatory compliance, and prepare clinical summaries to support potential law enforcement referrals or payment recoveries.
The AVP will lead the strategy, development, and negotiation of value-based contracts across the enterprise to lower healthcare costs. They are responsible for managing complex partnerships, aligning cross-functional stakeholders, and overseeing a high-performance team to achieve business objectives.
The Senior Proposal Writer is responsible for developing, writing, and revising compelling, compliant, and technically accurate content for government-sponsored health care RFPs. They collaborate with subject matter experts and stakeholders to ensure proposals effectively communicate business value and meet all submission requirements.
The Director of Member Experience develops and implements enterprise-wide strategies to achieve Medicaid membership retention goals and improve member satisfaction. This role drives process improvements across pharmacy, network, and provider relations while collaborating with leadership to ensure strategic alignment.
The Senior Specialist provides clinical support for quality improvement programs, audits, and federal/state compliance activities. They lead HEDIS medical record reviews and collaborate with cross-functional teams to ensure safe and efficient member care.
The specialist supports health plan provider engagement strategies to improve quality outcomes and risk adjustment accuracy. They drive provider coaching, facilitate data exchanges, and implement action plans to meet performance goals for assigned Tier 2 and Tier 3 providers.
The Eligibility Screener conducts face-to-face Adult Long-Term Care Functional Screens to determine program eligibility for IRIS participants. They also maintain accurate documentation, verify diagnosis information, and participate in team meetings to ensure regulatory compliance.
The Director of Performance Management is responsible for defining, implementing, and monitoring standardized performance metrics across the organization. They partner with data and analytics teams to ensure accurate reporting and provide actionable insights to support executive decision-making.
The Care Manager coordinates integrated care for members, conducting comprehensive assessments and developing personalized care plans. They facilitate interdisciplinary team meetings and monitor member progress to ensure quality, cost-effective outcomes.
Direct comprehensive data and analytics initiatives to enhance payer strategy, operational excellence, and clinical outcomes across diverse populations. Oversee enterprise reporting, integrate AI/ML solutions, and foster cross-functional partnerships to drive organizational growth.
The AVP of Encounters provides strategic leadership for the encounters function, ensuring accurate and timely submission of data to state and federal agencies. They manage cross-functional teams, oversee vendor performance, and implement process improvements to optimize operational efficiency and reduce healthcare costs.
The Care Review Clinician assesses member service requests to ensure medical necessity, cost-effectiveness, and compliance with clinical guidelines and regulations. They collaborate with multidisciplinary teams and medical directors to facilitate appropriate care delivery and utilization management.
The Care Manager provides support for care coordination activities and collaborates with a multidisciplinary team to manage integrated member care. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired health outcomes.
The RN will provide oversight, assessment, and guidance to participants in the IRIS Self-Directed Personal Care program. Responsibilities include developing person-centered care plans, conducting home visits, and providing training to participants and care providers.
The Care Manager coordinates integrated member care by conducting behavioral health assessments and developing personalized care plans. They monitor member progress, facilitate interdisciplinary team meetings, and provide ongoing support to ensure quality and cost-effective outcomes.
The nurse is responsible for reviewing medical documentation to ensure medical necessity and appropriate level of care using clinical guidelines. They also validate medical records and claims to ensure accurate billing and reimbursement for providers.
The Care Manager coordinates long-term services and supports for high-need members by developing and monitoring comprehensive care plans. They facilitate interdisciplinary team meetings, conduct member assessments, and provide ongoing support to ensure quality and cost-effective care delivery.
The Care Manager coordinates long-term services and supports for high-need members by developing care plans and conducting comprehensive assessments. They facilitate interdisciplinary team meetings and monitor member progress to ensure quality and cost-effective care delivery.
The Care Manager provides support for LTSS-specific activities and coordinates integrated care for members with high-need potential. They are responsible for conducting comprehensive assessments, developing care plans, and monitoring member progress toward desired outcomes.
The Care Manager coordinates long-term services and supports for members, developing and monitoring individualized care plans to ensure quality outcomes. They conduct comprehensive assessments, facilitate interdisciplinary team meetings, and authorize appropriate waiver services while maintaining member health and welfare.
The Program Director leads the Home Health Coordinator Planning Office, overseeing operational planning, financial management, and regulatory compliance for Florida CMS populations. This role acts as a central coordination point to ensure seamless service delivery, provider engagement, and the resolution of complex operational issues.
Lead data science and analytics initiatives to drive strategic decision-making and operational efficiency across healthcare domains. Oversee the development of data models and provide actionable insights through comprehensive analysis to optimize revenue and healthcare outcomes.
Leads a team providing subject matter expertise in Medicaid risk adjustment across multiple states. Responsibilities include analyzing data to identify risks, overseeing risk adjustment models, and providing technical guidance to actuarial staff.
Supports claims recovery by researching overpayment accuracy and provider compliance based on federal regulations and billing guidelines. Collaborates with health plans and vendors to facilitate the recovery of outstanding overpayments and manages the claims backlog.
The role focuses on process improvement, organizational change management, and managing complex projects within the managed healthcare payer growth portfolio. Key duties include estimating, scheduling, costing, and managing risks and issues across cross-functional teams.
The role involves reviewing inpatient and outpatient clinical claims to ensure that coded diagnoses, procedures, and DRG assignments accurately reflect documented clinical conditions. The reviewer identifies billing inconsistencies and develops evidence-based rationales to support reimbursement determinations.
The role supports Payment Integrity Prepay operations by researching coding edit inquiries and validating coding rationale to ensure accuracy. It involves partnering with Health Plans and vendors to monitor savings trends and resolve coding-related escalations.
Conduct medical necessity reviews for Medicare inpatient admissions and ongoing services using clinical guidelines and regulatory policies. Collaborate with providers and multidisciplinary teams to ensure cost-effective care delivery and regulatory compliance.
The clinician assesses clinical service requests to ensure medical necessity and compliance with Medicare guidelines and insurance policies. They collaborate with multidisciplinary teams and medical directors to optimize member outcomes and cost-effectiveness.
Responsible for managing internal business projects and programs, focusing on process and performance monitoring for members receiving private duty nursing services. The role involves coordinating with cross-functional teams to ensure effective service delivery, compliance, and the creation of project artifacts.
Leads the national provider services team focusing on enterprise network management, adequacy, and provider education. Serves as the primary liaison between the business and contracted providers to ensure compliance and satisfaction.
The clinician is responsible for reviewing clinical service requests to ensure medical necessity and compliance with established guidelines and regulations. They collaborate with multidisciplinary teams to optimize member outcomes and manage cost-effective care delivery.
Performs clinical audits across various functional areas to ensure compliance with regulatory requirements and quality standards. Reports outcomes to leadership and collaborates with training teams to address gaps in care and staff performance.
The clinician is responsible for verifying that medical services are necessary and align with clinical guidelines and insurance policies. They analyze service requests and collaborate with multidisciplinary teams to ensure cost-effective member care.
Provides senior-level support for health plan provider relations, focusing on network development, adequacy, and provider education. Serves as the primary point of contact for complex providers to ensure satisfaction and compliance with company policies.
Leads the development and implementation of value-based strategies and reimbursement models for government lines of business. Manages a high-performance team to improve risk adjustment revenue accuracy, compliance, and completeness.
Provides subject matter expertise for risk and quality performance solutions to improve health outcomes through data collection and analytics. Manages quality-related projects, ensures regulatory compliance for HEDIS audits, and collaborates with cross-functional teams to close care gaps.
The Director of Data Analytics leads the creation of executive reports and analytical insights to support member growth, retention, and customer experience. This role manages a team of analysts to monitor operational, clinical, and financial results across various interdepartmental functions.
Implement health plan provider engagement strategies to drive quality and risk adjustment outcomes for Tier 2 and Tier 3 providers. This involves coaching providers, analyzing data to improve performance, and addressing practice barriers to enhance health outcomes.
Leads the team responsible for health plan marketing and communications, ensuring all materials align with brand standards and regulatory requirements. Manages the development, distribution, and approval process for member and provider communications across various media platforms.
Provides audit support for risk adjustment activities by developing controls to minimize financial risks and losses. Manages data validation, monitors RAPS and EDPS transmissions, and ensures compliance with CMS regulations.
Leads and supervises the support center team to ensure excellence in customer service for Molina members and providers. Manages escalations, ensures regulatory compliance, and drives continuous quality improvement initiatives.
Leads the design and delivery of data-driven insights and regulatory reporting to support strategic and operational decision-making for the Florida Health Plan. Partners with executive leadership to translate complex healthcare data into actionable metrics for cost containment and compliance.
The clinician performs clinical reviews to ensure services are medically necessary and align with established guidelines for Medicare members. They manage the transition from inpatient care to discharge while collaborating with multidisciplinary teams to optimize member outcomes.
Provides analytical support for workforce management to ensure optimal staffing levels and coverage based on business needs. Responsible for forecasting call volumes, managing headcount requirements, and developing capacity templates.
The Lead Analyst acts as a data steward responsible for designing and prototyping Medical Economics data assets and translating complex business concepts into structured logic. They partner with stakeholders to define data requirements and ensure data quality and traceability across systems.
The clinician performs clinical member services reviews to ensure services are medically necessary and align with established guidelines. They manage the transition of Medicaid members from inpatient care to discharge locations while collaborating with multidisciplinary teams.
Provides senior-level financial analysis, reporting, and forecasting to support business decisions and the financial management of the IL health plan. Responsibilities include managing the monthly close process, developing financial models, and handling regulatory reporting.
The clinician assesses Medicare members to ensure medically necessary services and a successful transition from inpatient care to home or nursing facilities. They analyze clinical service requests against evidence-based guidelines and collaborate with multidisciplinary teams to optimize member outcomes.
Leads complex contracting activities with strategically critical provider groups, including hospitals and IPAs, to ensure network adequacy and financial performance. Negotiates value-based payment models and manages the optimization of provider relationships and reimbursement structures.
Provides entry-level analyst support for provider configuration by maintaining critical provider information across claims and provider databases. Ensures data accuracy and synchronization to support contracting, network management, and credentialing processes.
Provides non-clinical administrative support to the care management function, including case assignment, member screening, and scheduling. Facilitates communication and processes correspondence to support integrated delivery of care for members.
Responsible for performing utilization reviews and clinical determinations to ensure services are medically necessary and cost-effective. Collaborates with multidisciplinary teams to manage member care and ensure compliance with state and federal regulations.
The clinician is responsible for performing utilization reviews to ensure services are medically necessary and align with clinical guidelines. They analyze service requests, determine prior authorizations, and collaborate with multidisciplinary teams to optimize member outcomes.
Responsible for the architecture, design, and implementation of Big Data management solutions using Cloudera or Hortonworks. Focuses on building scalable data ingestion processes, data models for analytics, and leading a team of data professionals.
Lead enterprise data and analytics transformation initiatives by designing scalable, secure, and AI-ready data platforms using Databricks. Drive architecture strategy, platform modernization, and provide hands-on leadership from design through implementation.
Provides lead-level clinical support to healthcare services teams, coordinating integrated member care across various clinical programs. Responsibilities include supervising staff workload, resolving operational issues, and ensuring compliance with quality and productivity standards.
Lead complex contracting activities with strategically critical provider groups, including hospitals and behavioral health organizations. Manage the execution and optimization of value-based contracts while ensuring network adequacy and financial performance.
Serves as the primary point of contact between the health plan and contracted providers to ensure satisfaction and compliance with policies. Manages network development, conducts site visits, and delivers training to improve coordination and partnership.
Provides expert actuarial consultancy to identify risks, estimate liabilities, and establish premium rates. Supports financial analysis, reporting, and the creation of actuarial opinions and state reporting requirements.
Responsible for the intake and interpretation of regulatory and functional requirements related to coverage and reimbursement to support system solutions. This includes coordinating with stakeholders and maintaining requirement documents to ensure alignment with health plan and regulatory baselines.
Lead and manage Medicare Stars quality improvement programs and initiatives across the enterprise to improve Star ratings. Collaborate with cross-functional teams to design, implement, and measure the outcomes of quality improvement projects.
Lead and manage Medicare Stars quality improvement programs and initiatives across the enterprise to improve Star ratings. Collaborate with cross-functional teams to design, implement, and measure the outcomes of quality improvement projects.
Lead and manage Medicare Stars quality improvement programs and initiatives across the enterprise to improve Star ratings. Collaborate with cross-functional teams to design, implement, and measure the outcomes of quality improvement projects.
Leads the development and implementation of value-based strategies and programs to improve risk adjustment revenue and financial objectives. Manages a high-performance team and collaborates with leadership to design contracts and monitor performance via internal dashboards.
Provides senior-level support for the intake and interpretation of regulatory and functional requirements related to coverage and reimbursement. Coordinates with stakeholders to translate business needs into application requirements and ensures alignment across health plans.
Provides comprehensive behavioral health assessments and develops integrated care plans for members. Coordinates with multidisciplinary teams and conducts home or telephonic visits to monitor progress and ensure quality care.
Analyze enrollment data across various lines of business to resolve data issues and ensure compliance with CMS and state regulations. Develop reporting tools, dashboards, and algorithms to monitor business performance and support executive decision-making.
Lead quality improvement initiatives using QI science to support Medicare Stars measures and member intervention activities. Develop and implement evidence-based strategies to remove barriers to care and ensure compliance with NCQA and federal/state regulations.
Provides legal advisement on corporate governance, rights, and obligations while supporting Molina Healthcare's subsidiaries. Manages the drafting of corporate records and provides guidance to the corporate paralegal team.
Acts as a subject matter expert and advocate for Molina members regarding extra benefits and covered services to increase retention and satisfaction. Oversees the tracking and reporting of value-added benefits for Medicaid and MyCare Ohio while collaborating with internal and external stakeholders.
Lead a team of 10 direct reports responsible for ETL development, reporting support, and AI adoption across healthcare claims workstreams. Oversee the migration from SSIS to Azure Data Factory and ensure operational rigor in delivery processes.
Develops and maintains state and product-specific Medicare strategies through data analysis and market research. Leads high-priority operational improvement initiatives and coordinates cross-functional alignment across the organization.
Responsible for leading internal business projects and cross-functional teams to deliver products from design to completion. This includes managing CMS/HPMS submissions, overseeing project budgets, and collaborating with operational leaders for process improvements.
Leads the health plan provider network contracting activities, focusing on strategy, adequacy, and financial performance. Responsible for negotiating complex contracts, including value-based payment models and capitated payments for various healthcare entities.
Responsible for verifying that clinical services are medically necessary and align with established guidelines and insurance policies. The role involves analyzing service requests, processing prior authorizations, and collaborating with multidisciplinary teams to ensure cost-effective member care.
Develops and implements health education and disease management programs for members within the Molina network and the broader community. Conducts data collection and monitoring to ensure compliance with NCQA and state/federal standards.
Leads the reporting and analytics strategy to support business initiatives and management decision-making. Manages functional departments and ensures the quality and timely delivery of reports to provider networks and senior executives.
The analyst is responsible for interpreting regulatory requirements and coordinating with stakeholders to support system solutions. They also monitor policy updates, conduct root cause analysis, and ensure alignment across health plans and corporate functional areas.
This senior leadership role is responsible for defining and executing the enterprise data management strategy, modernization, and delivery across core health plan domains like claims, clinical, and member data. The director will lead the adoption of Databricks lakehouse architecture while ensuring data solutions are secure, compliant, and support advanced analytics and AI/ML use cases.
