18 Healthcare jobs in Morgantown

**JOB DESCRIPTION**
***Candidates must be located in California and work PST hours.***
**Job Summary**
Performs research and analysis of complex healthcare claims data, pharmacy data, and lab data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Develops, implements, and uses software and systems to support the department's goals.
+ Develops and generates ad-hoc and standard reports using SQL programming, excel , Databricks and other analytic / programming tools.
+ Coordinates and oversees report generation by team members and distribution schedule to ensure timely delivery to customers, ensuring the highest quality on every project/request. Responsible for error resolution, follow up and performance metrics monitoring.
+ Provides peer review of critical reports and guidance on programming / logic improvements; provides guidance to team members in their analysis of data sets and trends using statistical tools and techniques to determine significance and relevance.
+ Applies process improvements for the team's methods of collecting and documenting report / programming requirements from requestors to ensure appropriate creation of reports and analyses while reducing rework.
+ Manage the creation of comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.
+ Create new databases and reporting tools for monitoring, tracking, and trending based on project specifications.
+ Create comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.
+ Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
+ Maintains SharePoint Sites as needed, including training materials and documentation archives.
+ Demonstrate Healthcare experience in contract modeling, analyzing relevant Financial and Utilization Metrics of Healthcare.
+ Must be able to act as a liaison between Finance and Network Contracting as well as other external teams.
+ Must have experience in Financial modeling, identifying Utilization mgmt. trends and monitor pair mix.
+ Experience with Medicaid contract analytics is highly preferred.
+ Experience working on Managed care analytics and healthcare reimbursement models is required.
+ Must be able to work in a cross functional team.
**JOB QUALIFICATIONS**
**Required Education**
Bachelor's Degree in Finance, Economics, Computer Science
**Required Experience**
+ 6+ years of progressive responsibilities in Data, Finance or Systems Analysis
+ Expert knowledge on SQL, PowerBI, Excel, Databricks or similar tools
**Preferred Education**
Bachelor's Degree in Finance, Economics, Math, Accounting or related fields
Preferred experience in Medical Economics and Strong Knowledge of Performance Indicators:
+ Proactively identify and investigate complex suspect areas regarding contract rate and related medical costs
+ Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan
+ Apply investigative skill and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, etc.
+ Analysis of trends in medical costs to provide analytic support for finance, pricing, and actuarial functions
+ Multiple data systems and models
+ BI tools (Power BI)
**Preferred License, Certification, Association**
QNXT or similar healthcare payer applications
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $77,969 - $171,058 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**
**Job Summary**
Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Maintains critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems and application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Generates data to support continuous quality of provider data and developing SOPs and/or BRDs.
+ Develops and maintains documentation and guidelines for all assigned areas of responsibility.
+ Assists with development of configuration standards and best practices while suggesting improvement processes to ensure systems are working more efficiently and improve quality.
+ Assists in planning and coordination of the claim payment system upgrades and releases, including development and execution of some test plans.
+ Participates in the implementation and conversion of new and existing health plans.
**JOB QUALIFICATIONS**
**Required Education**
+ Bachelor's Degree in business administration, healthcare management, or a related field; or equivalent combination of education and experience
**Required Experience**
+ 5-7 years of business analysis experience
+ Proficiency in data analysis tools and techniques, such as Excel or SQL
+ Excellent communication, presentation, and interpersonal skills, with the ability to interact effectively with stakeholders at all levels
**Preferred Experience**
+ 7-9 years of business analysis experience
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
#PJCore
Pay Range: $77,969 - $141,371 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**
**Job Summary**
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
+ Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
+ Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required.
+ Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.
+ Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members post-discharge.
+ Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
+ Educates and supports member focusing on seven primary areas (ToC Pillars): medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and or Home and Community-based Services, and advance directives.
+ 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.
+ Facilitates interdisciplinary care team meetings and informal ICT collaboration.
+ RNs provide consultation, recommendations, and education as appropriate to non-RN case managers.
+ RNs are assigned cases with members who have complex medical conditions and medication regimens.
+ RNs will conduct medication reconciliation when needed.
**JOB QUALIFICATIONS**
**Required Education**
Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.
**Required Experience**
1-3 years hospital discharge planning or home health.
**Required License, Certification, Association**
+ Active, unrestricted State Registered Nursing (RN) license in good standing.
+ Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
**CALIFORNIA State Specific Requirements: Must be licensed currently for the state of California. California is not a compact state.**
**Preferred Education**
Bachelor's Degree in Nursing
**Preferred Experience**
3-5 years hospital discharge planning or home health.
**Preferred License, Certification, Association**
Active, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM)
***Work schedule :M - F Pacific Business Hours**
**Candidates can live anywhere in the USA but must work PACIFIC hours.**
**California or West Coast USA Residents preferred**
***Remote, no travel required.**
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
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 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**Description**
***$5k sign on bonus for eligible candidates!***
**Introduction**
Do you want to be appreciated daily? Our nurses are celebrated for being on the front line, empathetic for patients. At TriStar Greenview Regional Hospital our nurses set us apart from any other healthcare provider. We are seeking a(an) LPN Medical Surgical to join our healthcare family.
**Benefits**
TriStar Greenview Regional Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:
+ Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
+ Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
+ Free counseling services and resources for emotional, physical and financial wellbeing
+ 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
+ Employee Stock Purchase Plan with 10% off HCA Healthcare stock
+ Family support through fertility and family building benefits with Progyny and adoption assistance.
+ Referral services for child, elder and pet care, home and auto repair, event planning and more
+ Consumer discounts through Abenity and Consumer Discounts
+ Retirement readiness, rollover assistance services and preferred banking partnerships
+ Education assistance (tuition, student loan, certification support, dependent scholarships)
+ Colleague recognition program
+ Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
+ Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.
Learn more about Employee Benefits ( Eligibility for benefits may vary by location._**
At TriStar Greenview Regional Hospital, our nurses play a vital part. We know that every nurse's path and purpose is unique. Do you want to create your own personal career path in nursing? HCA Healthcare is your career destination! Our scale makes it possible for nurses to create the career path that fits their life - for life - and empowers their passion for patient care. Apply today for our LPN Medical Surgical opportunity.
**Job Summary and Qualifications**
As a Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) at HCA Healthcare, you'll play a key role in delivering safe, high-quality care that puts patients first. Your clinical skills, attention to detail, and compassionate presence help create healing experiences and support a team that's committed to the care and improvement of human life.
**Your responsibilities will include:**
+ Providing focused nursing care for patients with complex needs by administering medications, managing lines or drains, and assisting with interventions like cardiac monitoring or respiratory support
+ Closely observing patients for subtle changes in status - including shifts in heart rhythm, oxygen levels, or neurological signs - and escalating concerns quickly to support early intervention
+ Documenting timely, accurate updates that help the care team coordinate effectively in a high-acuity environment
+ Helping patients and families understand complex conditions and recovery steps with clarity and comfort
+ Working closely with RNs, providers, and specialists to stabilize patients and guide them through the transition from intensive care toward recovery
**What qualifications you will need:**
+ Basic Cardiac Life Support must be obtained within 30 days of employment start date
+ (LPN/LVN) Licensed Practical or Vocational Nurse
+ Vocational School Graduate
TriStar Greenview Regional Hospital is a 200+ bed facility serving Southern Kentucky and surrounding areas. Recognized by the Joint Commission as a _Top Performer on Key Quality Measures®_ , TriStar Greenview is a national leader in providing quality healthcare. **Home of Kentucky's first CardioMEMS HF System** , we are also an accredited chest pain center that provides state-of-the-art cardiac care to patients managing heart failure. The facility is also a Certified Primary Stroke Center.
"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
Join a family that cares about every stage in your career! We are interviewing candidates for our LPN Medical Surgical opening. **Apply today and a member of our Talent Acquisition team will reach out.**
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

**JOB DESCRIPTION**
**Job Summary**
Molina's Behavioral Health function provides leadership and guidance for utilization management and case management programs for mental health and chemical dependency services and assists with implementing integrated Behavioral Health care management programs.
**Knowledge/Skills/Abilities**
Provides Psychiatric leadership for utilization management and case management programs for mental health and chemical dependency services. Works closely with the Regional Medical Directors to standardized utilization management policies and procedures to improve quality outcomes and decrease costs.
- Provide regional medical necessity reviews and cross coverage
- Standardizes UM practices and quality and financial goals across all LOBs
- Responds to BH-related RFP sections and review BH portions of state contracts
- Assist the BH MD lead trainers in the development of enterprise-wide teaching on psychiatric diagnoses and treatment
- Provides second level BH clinical reviews, BH peer reviews and appeals
- Supports BH committees for quality compliance.
- Implements clinical practice guidelines and medical necessity review criteria
- Tracks all clinical programs for BH quality compliance with NCQA and CMS
- Assists with the recruitment and orientation of new Psychiatric MDs
- Ensures all BH programs and policies are in line with industry standards and best practices
- Assists with new program implementation and supports the health plan in-source BH services
- Additional duties as assigned
**Job Qualifications**
**REQUIRED EDUCATION:**
- Doctorate Degree in Medicine (MD or DO) with Board Certification in Psychiatry
**REQUIRED EXPERIENCE:**
- 2 years previous experience as a Medical Director in clinical practice
- 3 years' experience in Utilization/Quality Program Management
- 2+ years HMO/Managed Care experience
- Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.
- Knowledge of applicable state, federal and third-party regulations
**Required License, Certification, Association**
Active and unrestricted State (TX) Medical License, free of sanctions from Medicaid or Medicare.
**Preferred Experience**
- Peer Review, medical policy/procedure development, provider contracting experience.
- Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
#PJHS
#LI-AC1
Pay Range: $161,914.25 - $315,733 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**Job Description**
**Job Summary**
Molina's Quality Improvement Sr. Abstractor conducts data collection and abstraction of medical records for HEDIS projects, HEDIS like projects and supplemental data collection. The abstraction team will meet chart abstraction productivity standards as well as minimum over read standards. Sr. Abstractors will also provide mentoring to entry level abstractors.
**Job Duties**
+ Performs the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.
+ Participates in meetings with vendors for the medical record collection process.
+ As needed, may collects medical records and reports from provider offices, loads data into the HEDIS application, and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly performed.
+ Participates in scheduled meetings with the National Over read team, National Training Team, Regional HEDIS team, vendors and HEDIS auditors regarding quality and HEDIS review and results.
+ Assists with projects and process improvement initiatives
+ Mentors entry level Abstractors
**Job Qualifications**
**REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:**
Bachelor's degree or equivalent experience
**REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E/KNOWLEDGE, SKILLS & ABILITIES:**
+ 3 years experience in healthcare Quality/HEDIS specific to medical record review and abstraction
+ Intermediate knowledge and understanding of HEDIS projects
**PR** **E** **FE** **R** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:**
+ At least 3 years of medical record abstraction experience
+ 3+ years managed care experience.
+ Advanced knowledge of HEDIS and NCQA
**PR** **E** **FE** **R** **RED L** **I** **C** **E** **N** **S** **E,** **C** **E** **R** **TI** **FI** **C** **A** **T** **I** **O** **N** **, AS** **S** **O** **C** **I** **A** **TI** **O** **N** **:**
Active RN license for the State(s) of employment
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $21.82 - $42.55 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**PURPOSE** **AND** **SCOPE:**
Functions as part of the dialysis health care team in providing safe and effective dialysis therapy for patients under the direct supervision of a licensed nurse in accordance with organization policies, procedures, and training and in compliance with regulations set forth by the corporation, state, and federal agencies. Responsible for the setup and operation of hemodialysis machines. Assist in the maintenance of a safe and clean working environment. Supports the organization commitment to the Quality Enhancement Program (QEP) and CQI Activities, including those related to patient satisfaction and actively participates in process improvement activities that enhance the likelihood that patients will achieve the organization Quality Enhancement Goals (QEP).
**PRINCIPAL** **DUTIES** **AND** **RESPONSIBILITIES:**
**Patient Related**
Education:
+ Assist other health care members in providing patient specific detailed education regarding adequacy measures where appropriate - Online Clearance Monitoring (OLC), Adequacy Monitoring Program (AMP), Urea Kinetic Modeling (UKM), and regarding disease process/access.
Treatment:
+ Welcome assigned patients and inquire as to their wellbeing since their last treatment.
+ Evaluate vascular access for patency, perform vascular access cannulation, and perform administration of heparin as delegated or as allowed by state law.
+ Obtain necessary pre and post treatment vital signs and weight and perform vascular access evaluation pre- treatment
+ Initiate dialysis treatment according to prescribed orders including blood flow (QB) and dialysate flow (QD).
+ Evaluate intradialytic problems and provide intervention as prescribed by physician order or as directed.
+ Monitor patients' response to dialysis therapy.
+ Obtain vital signs prior to reinfusion; perform all relevant functions necessary for the discontinuation of treatment - document.
+ Discontinue dialysis treatment according to established procedures and evaluate patient prior to termination of venous access - standing & sitting blood pressure
+ Obtain Hemostasis and apply appropriate dressings.
+ Evaluate the patient prior to discharge.
+ Perform and record Pre and Post dialysis evaluation, weight, and vital signs with initial identification
+ Responsible for calculating and entry of individual patients' dialysis machine programming for Ultrafiltration (UF) goal; treatment time; and UF modeling as prescribed.
+ Responsible for ensuring appropriate safety alarms are enabled, including Narrow Venous Limits, (NVL) 160.
+ Record accurate and timely information regarding vital signs and treatment parameters onto the Hemodialysis Treatment Sheet with initial identification
+ Responsible for accurate documentation of information related to patient treatment including completion of Hemodialysis Treatment Sheet and, if applicable, progress notes.
+ Report any significant information and/or change in patient condition directly to the registered nurse or supervisor.
+ Observe patient and conduct machine safety checks according to facility policy. Report any change or unusual findings to the registered nurse or supervisor.
+ Perform and document any intervention for unusual patient status and document patients' response to intervention.
+ Evaluate patients' vascular access during treatment including arterial and venous monitoring pressures, provide appropriate intervention as needed, document and report any unusual findings to the registered nurse or supervisor.
+ Obtain all prescribed laboratory testing and prepare specimens for collection.
+ Ensure that all blood spills are immediately cleaned with appropriate disinfectant according to facility policy.
+ Prepare, organize, and efficiently utilize supplies and equipment to prevent wastage.
+ Monitors patients performing self-care under the supervision of RN.
**Staff Related**
+ Assists in training of applicable direct patient care staff on appropriate programs under the supervision of a nurse.
**Education/Communication:**
+ Follows all organization business policies, procedures and systems incorporated into training, including compliance with ethical business practices
+ Maintain environmental integrity and aesthetics - ensure all areas are safe and clean.
+ Clean and disinfect dialysis machine surface, chair, equipment, and surrounding area between treatments according to facility policy.
+ Conduct all tasks necessary for preparation for dialysis treatment and document where appropriate and perform all required pretreatment dialysis machine alarm testing including Pressure Holding (PHT).
+ Initiate Solution Delivery System (SDS) system.
**RECORD KEEPING:**
+ Complete and document ongoing participation in Continuous Quality Improvement (CQI) activities.
+ Enters all treatment data into the designated clinical application in an accurate and timely manner.
+ Review treatment sheets for completeness, ensure nursing signatures are documented, and ensure
omitted entries are completed or corrected by appropriate staff.
+ Prepare initial patient chart for admission and compile paperwork for appropriate placement in chart.
+ Prepare/print lab requisitions for prescribed or stat Lab specimens according to laboratory destination.
+ Collect, label, appropriately prepare and store lab samples according required laboratory specifications.
+ Ensure collection of lab specimens by appropriate lab courier.
**INFECTION CONTROL:**
+ Assists in collecting information for infection control audits.
+ Supports staff and patient Adherence to infection control practices.
+ Follows infection control Policies and Procedures
+ Participates in and reinforces infection control education of patients and families under the direction of the CM or designee as allowed by state law.
**TRANSITIONAL CARE UNIT:**
+ Follows all newly admitted patients through their first 4 weeks of dialysis and coordinating their transitional dialysis care
+ Reinforces all education and care related matters as it relates to the new patient as allowed by state law
+ Liaisons with appropriate FKC staff members to provide the best patient experience including making sure all disciplines are scheduled to see patient according to plan.
+ Assists in assuring patient understanding or home dialysis products, benefits of home and how home dialysis can work for them.
+ Sets and preforms a treatment on all machines used in the transitional care unit.
+ Assist in assuring patient understanding of treatment options including demonstration of the peritoneal dialysis set-up.
+ Assists with coordination of transition to patient's modality choice.
+ Assists with supply ordering and inventory for TCU
**PHYSICAL** **DEMANDS** **AND** **WORKING** **CONDITIONS:**
+ The physical demands and work environment characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.
+ Employees are required to take the Ishihara's Color Blindness test as a condition of employment. Note that: Failing the
Ishihara Test for Color Blindness does not preclude employment. The Company will consider whether reasonable
accommodations can be made.
+ Day to day work includes desk and personal computer work and interaction with patients, facility staff, and physicians. The position requires travel between assigned facilities and various locations within the community. Travel to regional, Business Unit and Corporate meetings may be required.
+ The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials
+ The position provides direct patient care that regularly involves heavy lifting and moving of patients and assisting with ambulation.Equipmentaidsand/orcoworkersmayprovideassistance.Thispositionrequiresfrequent,prolongedperiodsof standing and the employee must be able to bend over. The employee may occasionally be required to push and/or pull equipment, exerting up to 15 pounds of force. The employee may be required to lift and to lower solutions on a frequent basis of up to 30 lbs., and on an occasional lift basis up to 40 lbs., as high as 5 feet. There is a two-person assist program and "material assist" devices for the heavier items.
**EDUCATION** **AND** **LICENSES:**
+ HighSchooldiplomaorG.E.D. required.
+ Must meet Center for Medicaid/Medicare Services (CMS)-approved state and/or national certification requirements within the required state or CMS timeline.
+ Allappropriatestatelicensure,education,andtraining(ifany) required.
+ Demonstrated commitment to organization culture, values, and customer service standards
**EXPERIENCE AND REQUIRED SKILLS** **:**
+ Previouspatientcareexperienceinahospitalsettingorarelatedfacility preferred.
+ Continued employment is dependent on successful completion of the organization dialysis training program and successful completion of CPR certification.
**_EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity_**
**Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.**
**EOE, disability/veterans**

**JOB DESCRIPTION**
**Job Summary**
Molina Health Plan Provider Network Management and Operations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state, and local regulations. Provider Services staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for the provider training, network management and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Under general supervision, responsible for various provider services functions with an emphasis on working externally with the Plan's highest priority, high volume, strategic providers to educate, advocate and engage as valuable partners.
+ Requires an in-depth knowledge of provider services and contracting subject matter expertise.
+ Resolves complex provider issues that may cross departmental lines and involve Senior Leadership.
+ Serves as a subject matter expert for other departments.
+ Trains other Provider Services Representatives, as appropriate.
**JOB QUALIFICATIONS**
**Required Education**
Bachelor's Degree or equivalent provider contract, network development and management, or project management experience in a managed healthcare setting.
**Required Experience**
+ 3 - 5 years customer service, provider service, or claims experience in a managed care setting.
+ 3-5 years' experience in managed healthcare administration and/or Provider Services.
+ 5 years' experience in provider contract negotiations in a managed healthcare setting ideally in negotiating different provider contract types, i.e., physician, group and hospital contracting, etc.
+ Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to; fee-for service, capitation, and various forms of risk, ASO, etc.
**Preferred Education**
Bachelor's or master's degree.
**Preferred Experience**
+ 5+ years' experience in managed healthcare administration and/or Provider Services.
+ 5+ years' experience in provider contract negotiations in a managed healthcare setting ideally in negotiating different provider contract types, i.e., physician, group and hospital contracting, etc.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $77,969 - $116,835 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**
**Job Summary**
The Manager, Medical Economics provides support and consultation to the Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level Suite executives to mitigate these trends.
Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities.
**KNOWLEDGE/SKILLS/ABILITIES**
Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths.
+ Extract and compile information from various systems to support executive decision-making
+ Mine and manage information from large data sources.
+ Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs.
+ Work with clinical, provider network and other personnel to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions.
+ Work with business owners to track key performance indicators of medical interventions
+ Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives
+ Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect/problem areas, and suggest a corrective action plan
+ Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise
+ Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management
+ Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports
+ Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes
+ Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making
+ Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same
+ Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results
+ Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare
**JOB QUALIFICATIONS**
**Required Education**
Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field
**Required Experience**
+ 3 years management or team leadership experience
+ 10 years analytical work experience within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.)
+ Strong Knowledge of SQL and PowerBI report development
+ Familiar with relational database concepts, and SDLC concepts
**Preferred Education**
Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field.
**Preferred Experience**
+ 3 - 5 years supervisory experience
+ Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans
+ Experience with Databricks
+ Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.)
+ Proficiency with Excel and SQL for retrieving specified information from data sources.
+ Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.)
+ Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form)
+ Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG's), Ambulatory Patient Groups (APG's), Ambulatory Payment Classifications (APC's), and other payment mechanisms. - Understanding of value-based risk arrangements
+ Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in healthcare
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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Pay Range: $88,453 - $172,484 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.