Advanced Practice Nurse Practitioner

• Demonstrates and facilitates conformance to Medicare, Medicaid, National Committee for Quality Assurance (NCQA) and other regulatory requirements.

• Reviews quality referred issues, focused reviews and recommends corrective actions.

• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and others as directed by the chief medical officer.

• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process.

• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.

• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

• Develops and implements plan medical policies.

• Provides implementation support for quality improvement activities.

• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions if needed.

• Collaborates with contracting department in contract negotiations.

• Fosters clinical practice guideline implementation and evidence-based medical practices.

• Utilizes information technology and data analysts to produce tools to report, monitor and improve utilization management.

• Actively participates in regulatory, professional and community activities.

Required Qualifications

• At least 8 years of health care experience, including 5 years of clinical practice experience, 3 years utilization/quality program management experience, and 2 years managed care experience, or equivalent combination of relevant education and experience.

• Advanced Practice Registered Nurse (APRN) license. License must be active and unrestricted in the state of practice.

• Current clinical knowledge.

• Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations.

• Ability to work independently, with minimal supervision and demonstrate self-motivation.

• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.

• Excellent time-management and prioritization skills; ability to focus on multiple projects simultaneously and adapt to change.

• Excellent problem-solving and critical-thinking skills.

• Ability to work in a high-pressure environment.

• Ability to maintain attendance to support required quality and quantity of work.

• Ability to maintain confidentiality and comply with health insurance portability and accountability act (HIPAA).

• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

• Knowledge of applicable state, federal and third party regulations.

• Strong verbal and written communication skills.

• Microsoft Office proficiency, and ability to navigate an electronic medical record (EMR) system.

Preferred Qualifications

• Board certification (primary care preferred).

• Peer review, medical policy/procedure development, and/or provider contracting experience.

• Experience with National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data Information Set (HEDIS), Medicaid, Medicare and Pharmacy Benefit Management (PBM), Group/IPA practice, capitation, health management organization (HMO) regulations, managed health care 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 Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Job Info

Job Identification: 2034612

Job Category: Clinical

Posting Date: 2025-10-30T22:40:42 00:00

Job Schedule: Full time