Director, Operational Oversight - D-SNP Payment Operations

Leads and directs team responsible for operational oversight activities, including oversight of internal operating controls and processes/practices (auditing, root-cause analysis, compliance, etc.).  Compiles and shares outcomes with operations functional areas for review and action.  Ensures that findings are corrected within appropriate time frames and in accordance with cost-control and regulatory standards.  Responsible for identifying regulatory compliance risks within operations functions, mitigating identified risks, ensuring compliance and regulatory oversight, and driving improvement activities in function support areas.  May also be responsible for oversight and performance for select operational area(s).

Essential Job Duties

• Directs team responsible for auditing, analysis, and compliance activities supporting oversight of operational areas across the business.  
• Leads operational oversight review/regulatory compliance of corporate operations functions - includes internal and external audit oversight and core operations functional support.  
• Represents as primary liaison between regulatory auditors and corporate operations business units, leadership and line personnel from receipt of notification from regulatory agency through analysis and response to findings. 
• Organizes audit submissions and interacts directly with auditors for all lines of business as it relates to audits.
• Represents as a voting representative for delegation oversight committees.
• Liaises with the special investigative unit (SIU) on program integrity and oversight cost expenditure.
• Monitors internal compliance of corporate operations units via the internal compliance program, and annual, periodic, and focal audits.
• Requests, reviews and performs oversight of internal corrective action plans (CAPs) for both internal and external audit findings via coordination of responses - ensuring appropriateness as it relates to the finding.
• Reviews and approves corporate operations policies, procedures, guidelines and job aids to ensure compliance with state, federal, and internal regulations.
• Develops and maintains the corporate operations compliance program, including compliance policies and procedures, and implementation of audits and monitoring.
• Collaborates with corporate legal to address legal actions (e.g. third-party liability, provider and member lawsuits).
• Maintains awareness of current laws, regulations, statutes, etc. for each state that Molina has existing business.  
• In collaboration with local health plans, analyzes and interprets regulations that affect corporate operations policies, procedures and guidelines, and ensures updated inclusion in applicable documents.
• Coordinates with health plans for Office of Inspector General (OIG) and Office of the Attorney General (OAG) and other state office of internal/attorney general requests for data.
• Assists with request for proposal (RFP) responses.
• Proactively works with enterprise operations leadership on operational effectiveness to ensure organizational compliance.
• Collaborates with and develops rapport with health plan compliance and government contracts personnel to ensure alignment related to contractual requirements and state/federal/internal guidelines.
• Hires, trains, and manages performance of team; demonstrates accountability for performance and delivery.

If oversight of specific operational areas apply:
• Oversees performance and financial results for select operational units.  
• Serves as primary point of contact for all matters related to operational units, and achievement of service level agreements (SLAs) and other contractual requirements under assigned areas of responsibility.
• In conjunction with leadership, establishes performance goals to support overall operational unit objectives.
• Develops budget inputs for areas of responsibility.
 

Required Qualifications

• At least 8 years of experience in health care operations, operational oversight, auditing, government regulations and/or compliance, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Strong operations experience in a managed care organization.
• Health insurance claims processing experience.
• Experience supporting Medicare, Medicaid, and Marketplace plans.
• Strong attention to detail, critical-thinking and problem-solving abilities.
• Strong data processing/analysis experience.
• Ability to multitask, stay organized, and manage multiple projects simultaneously.
• Ability to learn new information systems and software programs.
• Ability to establish and maintain positive and effective work relationships with internal and external stakeholders and work collaboratively in a highly matrixed organization.
• Strong project management experience.
• Strong verbal/written/interpersonal communication skills.  
• Microsoft Office suite proficiency (including Excel), and applicable software programs proficiency.
 

Preferred Qualifications

• Strong regulatory/compliance experience in a managed care environment.
• Project Management Professional (PMP) certification.
 

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