Job description

Title: Clinical Program Manager, Managed Care (Molina San Diego)

Classification: EXEMPT

Actual offers will be determined by the candidate’s creditable years of experience in conjunction with internal equity considerations and based on the organization’s current compensation practices.

Job Code: 715

Job Summary

Works within the vision, mission, and philosophy of the agency. Hires, develops, trains, manages, and retains clinical program staff and a clinical team(s) to ensure customer satisfaction and culturally competent service delivery. Functions as the liaison between team, payers, and community partners. Provides fiscal stewardship of team, acts as a bridge between fiscal and other departments. Ensures provision of high quality service by program staff through clinical supervision and monitoring of program KPIs.

Essential Duties

Clinical Care Management

Ensures effective quality clinical services delivery for assigned healthplan members.

Develops, interprets and ensures consistent implementation of clinical program philosophy, objectives, standards, policies, procedures and practices.

Analyzes and integrates the use of outcome data to improve clinical service delivery within assigned team.

Ensures and monitors satisfaction and defined outcome achievement for health plan members.

Provides effective crisis and risk prevention and management.

Provides 24/7 availability as needed. Culturally responsive to internal and external customers, and ensures family voice.

Provides direct services to health plan members, as support to the direct service staff, to ensure smooth delivery of service.

Responsible for managing referrals (e.g., electronic, telephonic, manual) and assigning accordingly

Program & Fiscal Management

Manages day-to-day operations including utilization of all administrative electronic systems, human, and other resources.

Ensures staff engage health plan members for enrollment and other revenue related activities meet or exceed revenue forecasts to ensure viable programming.

Ensures compliance with all policy and procedures including adherence to all licensing, quality, Information Technology (IT), Human Resources (HR), compliance and regulatory standards.

Ensures clinical documentation and quality assurance meets both agency and payor standards, ensuring audit ready charts and continuous quality improvement.

Effectively manage individual and program utilization rates

Implement scaffolded structures and process to address immediate needs (initial implementation) and long-term solution (full implementation)

Responsible for managing operations metrics at appropriate frequency to effectively manage the program, staffing pattern, and clinical needs

Advocate for business needs to balance agency process and alternative payor requirements

Works collaboratively with managerial peers to develop and improve program delivery and ensure adherence to fiscal requirements.

Personnel Management

Participates in staff development; hires, coaches, mentors, supervises, conducts direct field

observations, trains, disciplines, and terminates.

Leads and manages change.

Proactively identifies potential conflicts and facilitate resolution

External Liaison

Ensures effective coordination of services for health plan members with other providers, both internal and external, by supporting the development of constructive relationships and problem-solving barriers.

Provides outreach to the community regarding managed care and behavioral health.

Quality Assurance and Improvement

Initiates and participates in organizational quality improvement efforts. Lead and/or delegate work groups to respond to program development needs.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

Education/Education Requirements

• Master’s Degree (MA/ MS) required.
• 5 years direct clinical experience, with 3 years in Behavioral Health, Primary Care, or Public Health
• Managed Care or commercial health plan experience (e.g., Patient engagement conversion, utilization management) preferred
• Experience working with all ages preferred
• New program start-up (preferred)

Other Specific Requirements

• Must pass Department of Justice (DOJ), Federal Bureau of Investigations (FBI), and Child Abuse Index Check (CAIC) background clearance.
• Valid California Driver's license with two years experience driving and clean driving record may be required.

Work Environment/Conditions

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee may be required to use hands to handle or feel objects, tools or controls; reach with hands and arms; and taste or smell. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

In addition, this position requires sitting, standing, walking, climbing and kneeling.

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Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the Los Angeles Fair Chance Initiative for Hiring.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

EOE

Job Type: Full-time

Pay: From $72,732.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Parental leave
• Referral program
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: Hybrid remote in San Diego, CA 92123

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