Qureos Mentor

Molina Healthcare

Molina Healthcare is a FORTUNE 500 company dedicated to government-sponsored health care programs for eligible families and individuals. The company contracts with state governments to provide a variety of health care services, including Medicaid and Medicare plans, across multiple states including California, Texas, and New York. Molina Healthcare aims to improve access to quality health care and participates in initiatives to enhance community health and well-being.

<div>JOB DESCRIPTION

Performs research and analysis of complex healthcare claims data, vendor data, financial data, pharmacy data, and lab data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost reconcilliation reports and makes recommendations based on relevant findings. In addition, contribute to ensuring accurate KPIs and complete data is reported internally and externally.

KNOWLEDGE/SKILLS/ABILITIES
<ul>
<li>Develop ad-hoc reports using SQL programming, SQL Server Reporting Services (SSRS), Excel, AI when available, Executive Dashboard, and other analytic / programming tools as needed.</li>
<li>Generate and distribute standard reports on schedule using SQL, Excel, and other reporting software.</li>
<li>Create new databases and reporting tools for monitoring, tracking and trending based on project specifications.</li>
<li>Collects and documents report / programming requirements from requestors to ensure appropriate creation of reports and analyses. Uses peer-to-peer review process and end-user consultation to reduce report writing errors and rework.</li>
<li>Responsible for timely completion of projects, including timeline development and maintenance; coordinates activities and data collection with requesting internal departments or external requestors.</li>
<li>Identify and complete report enhancements/fixes; modify reports in response to approved change requests; retain old and new report design for audit trail purposes.</li>
<li>Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation, and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors.</li>
<li>Create comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.</li>
<li>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.</li>
<li>Maintains SharePoint Sites as needed.</li>
</ul>
JOB QUALIFICATIONS

Required Education

Bachelor's Degree in Finance, Economics, Computer Science

Required Experience
<ul>
<li>5-7 years increasingly complex database and data management responsibilities</li>
<li>5-7 years of increasingly complex experience in quantifying, measuring, and analyzing financial/performance management metrics
</li><li>Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare</li>
<li>Experience working on SQL for data analysis, trend analysis, forecasting and predictive analysis</li></ul> 


Preferred Experience
<ul>
<li>Preferred experience in Medical Economics and Strong Knowledge of Performance Indicators:</li>
<li>Proactively identify and investigate complex suspect areas regarding medical cost issue</li>
<li>Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan</li>
<li>Apply investigative skill and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modeling, etc.</li>
<li>Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions</li>
<li>Healthcare Analyst I or Financial/Accounting Analyst I experience desired</li>
<li>Multiple data systems and models</li>
<li>BI tools 
</li></ul>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.</div>

Senior Data Analyst, Healthcare Analytics

<div>JOB DESCRIPTION

Job Summary

Provides support and ownership for medical economics analysis activities, including extracting, analyzing and synthesizing data from various sources to identify risks and opportunities and improve financial performance.

Essential Job Duties
<ul><li>Extracts and compiles data and information from various systems to support executive decision-making.</li><li>Mines and manages information from large data sources.</li><li>Analyzes claims and other data sources to identify early signs of trends or other issues related to medical care costs.</li><li>Analyzes the financial performance, including cost, utilization and revenue of all Molina products - identifying favorable and unfavorable trends, developing recommendations to improve trends and communicating recommendations to leadership.</li><li>Draws actionable conclusions based on analyses performed, makes recommendations through use of health care analytics and predictive modeling, and communicates those conclusions effectively to audiences at various levels of the enterprise.</li><li>Performs pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives.</li><li>Collaborates with clinical, provider network and other teams to bring supplemental context/insight to data analyses, and design and perform studies related to the quantification of medical interventions.</li><li>Collaborates with business owners to track key performance indicators of medical interventions.</li><li>Proactively identifies and investigates complex suspect areas regarding medical cost issues, initiates in-depth analysis of suspect/problem areas and suggests corrective action plans.</li><li>Designs and develops reports to monitor health plan performance and identify the root causes of medical cost trends - with root causes identified, drives innovation through creation of tools to monitor trend drivers and provides recommendations to senior leaders for affordability opportunities.</li><li>Leads projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports.</li><li>Serves as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes</li><li>Provides data driven analytics to finance, claims, medical management, network, and other departments to enable critical decision making.</li><li>Supports financial analysis projects related to medical cost reduction initiatives.</li><li>Supports medical management by assisting with return on investment (ROI) analyses for vendors to determine if financial and clinical performance is achieving desired results.</li><li>Keeps abreast of Medicaid and Medicare reforms and impact on the Molina business.</li><li>Supports scoreable action item (SAI) initiative tracking to performance.</li></ul>
<div>
Required Qualifications 
<ul><li>At least 3 years of health care analytics and/or medical economics experience, or equivalent combination of relevant education and experience.</li><li>Bachelor&rsquo;s degree in statistics, mathematics, economics, computer science, health care management or related field.</li><li>Demonstrated understanding of Medicaid and Medicare programs or other health care plans.</li><li>Analytical work experience within the health care industry (i.e., hospital, network, ancillary, medical facility, health care vendor, commercial health insurance, large physician practice, managed care organization, etc.)</li><li>Proficiency with retrieving specified information from data sources.</li><li>Experience with building dashboards in Excel, Power BI, and/or Tableau and data management.</li><li>Knowledge of health care operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.)</li><li>Knowledge of health care 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).</li><li>Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG&rsquo;s), Ambulatory Patient Groups (APG&rsquo;s), Ambulatory Payment Classifications (APC&rsquo;s), and other payment mechanisms.</li><li>Understanding of value-based risk arrangements</li><li>Experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in health care.</li><li>Ability to mine and manage information from large data sources.</li><li>Demonstrated problem-solving skills.</li><li>Strong critical-thinking and attention to detail.</li><li>Ability to effectively collaborate with technical and non-technical stakeholders.</li><li>Strong time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.</li><li>Effective verbal and written communication skills.</li><li>Proficient in Microsoft Office suite products, key skills in Excel (VLOOKUPs and pivot tables)/applicable software program(s) proficiency.</li></ul> 
</div>Preferred Qualifications
<ul><li>Proficiency with Power BI and/or Tableau for building dashboards.</li></ul> 
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</div>

Senior Analyst, Medical Economics - REMOTE

<div>JOB DESCRIPTION Job Summary
Provides support for Molina Medicare sales activities. Responsible for increasing membership through direct sales and marketing of Molina Medicare products to dual eligible, Medicare-Medicaid recipients within market areas to achieve revenue, profitability and retention goals. Adheres to ethical sales practices, compliance with Centers for Medicare and Medicaid Services (CMS), and other regulatory requirements. 


Essential Job Duties
<ul><li>Deploys sales strategies to procure a sufficient number of referrals and other self-generated leads to meet sales targets through active participation in community events and targeted community outreach to group associations, community centers, senior centers, senior residences, and other potential marketing sites.</li><li>Assists in generating leads through referrals and local outreach efforts.</li><li>Follows up on assigned company-generated leads promptly.</li><li>Supports scheduling of individual meetings and group presentations from assigned leads.</li><li>Works toward achieving monthly sales goals as set by leadership.</li><li>Participates in sales presentations with potential customers and assists in tailoring presentations to customer needs.</li><li>Assists eligible individuals in enrollment in Molina Medicare products by guiding them through the application process and ensuring accurate documentation.</li><li>Provides clear and accurate information to Medicare beneficiaries about product options, enrollment steps, and service contacts.</li><li>Maintains records of sales activities and updates lead status regularly in Salesforce.</li><li>Travels locally within assigned sales territories.</li></ul> 
Required Qualifications
<ul><li>At least 2 years of experience with Medicare, Medicaid, Marketplace, and/or other health insurance-related sales, or equivalent combination of relevant education and experience.
</li><li>Active and unrestricted Life &amp; Health insurance license.</li><li>Must have reliable transportation for travel throughout assigned sales territory.</li><li>Knowledge/understanding of community resources.</li><li>Customer service/sales skills.
</li><li>Multi-tasking and organizational skills.</li><li>Experience working with senior citizens and low income individuals.</li><li>Effective verbal and written communication skills, and relationship building skills.</li><li>Microsoft Office suite and applicable software programs proficiency.</li></ul> 
Preferred Qualifications
<ul><li>Medicare-specific knowledge/experience.</li><li>Bilingual.</li></ul> 
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</div>

Account Representative, Medicare Sales

Molina Healthcare is hiring for a remote Pharmacist, UM/Prior Auth. Essential Job Duties Provides support and subject matter expertise for pharmacy formulary liaison activities between the business and its customers (members, providers and pharmacies) to determine coverage and informative drug use. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. The hours will be Monday through Friday 10am- 630 central time with rotating weekends. <ul><li>Acts as a liaison between Molina and its customers (members, providers and pharmacies) with respect to the pharmacy benefit.</li><li>Serves as the designated formulary expert.</li><li>Ensures Molina is compliant with the coverage determination and appeals process.</li><li>Contributes to projects aimed at improving STAR ratings, Healthcare Effectiveness Data Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Services (CAHPS), and other quality metrics.</li><li>Assists call center pharmacy technicians with clinical questions and phone calls from prescribers, pharmacies and/or members.</li><li>Develops, implements and maintains pharmacy cost-control and quality initiatives under the direction of leadership.</li><li>Monitors drug utilization and assists leadership team in understanding quality and cost-control issues related to pharmacy.</li><li>Works in tandem with Molina medical directors to ensure accurate coverage determination decisions.</li><li>Works with leadership on developing annual training sessions for applicable staff regarding the pharmacy benefit changes for the upcoming year.</li><li>Works with the care management department as part of a member-centered interdisciplinary care team (ICT).</li><li>Works with the Pharmacy Benefit Manager (PBM) to manage formulary changes and update marketing on any changes needed on the web or print versions of the formulary.</li><li>Performs outreach to members and physicians as part of quality and/or cost-control initiatives.</li><li>Provides leadership for the pharmacy call center team under the direction of pharmacy senior leadership.</li><li>Identifies and implements programs to improve clinical outcomes stemming from medication selection, utilization, and adherence.</li></ul>Required Qualifications <ul><li>At least 3 years of experience in a pharmacy, Pharmacy Benefit Manager(PBM), formulary, and/or managed care setting, and 1-2 years post-graduate experience, or equivalent combination of relevant education and experience.</li><li>Active and unrestricted Doctor of Pharmacy (PharmD) in applicable state(s). &bull; Current knowledge and expertise in clinical pharmacology and disease management.</li><li>Ability to present ideas and information concisely to varied audiences.</li><li>Knowledge of processes and systems necessary to develop and deliver training to departmental staff and internal customers.</li><li>Ability to develops and maintains positive and effective work relationships with coworkers, members, providers, regulatory agencies and vendors.</li><li>Proficiency compiling data, creating reports and presenting information.</li><li>Ability to meet established deadlines.</li><li>Functions independently and manages multiple projects.</li><li>Excellent verbal and written communication skills.</li><li>Microsoft Office suite (including Excel), and applicable software program(s) proficiency.</li></ul>Preferred Qualifications <ul><li>Medicare Part D and/or Medicaid experience.</li><li>Managed care experience.</li></ul>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 Pay Range: $72,370.82 - $156,803.45 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Pharmacist, Utilization Management (Remote)

<div>
 Molina Healthcare is hiring for a Pharmacist in our UM/Prior Authorization department. Candidates must be licensed to practice in the state of Florida or be able to obtain Florida licensure within 90 days of starting. This position is remote and can be worked from a variety of locations within the US.
 
 
 Shift times can be either 8 or 10 hour shifts between the times of 7a and 10p EST with rotating weekends
 
 depending on business needs.
 
 
 
 Molina Pharmacy Services/Management staff work to ensure that Molina members have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).
 
 
 
 Knowledge/Skills/Abilities
 
 
 
 The Pharmacist, UM will be responsible for reviewing coverage determinations and appeals in a timely, compliant, and accurate manner. The Pharmacist, UM will also be responsible for serving as a formulary and drug information resource, assisting technicians and other departments with questions regarding drug coverage.
 
 
 <ul>
 <li>
 Acts as a liaison between Molina and its customers (members, providers and pharmacies) with respect to the pharmacy benefit.
 </li>
 <li>
 Serves as the formulary expert.
 </li>
 <li>
 Ensures Molina is compliant with the coverage determination and appeals process.
 </li>
 <li>
 Contributes to projects aimed at improving Star ratings, HEDIS, CAHPS, and other quality metrics.
 </li>
 <li>
 Assists call center pharmacy technicians with clinical questions and phone calls from prescribers, pharmacies and/or members.
 </li>
 <li>
 Develops, implements and maintains pharmacy cost control and quality initiatives under the direction of leadership.
 </li>
 <li>
 Monitors drug utilization and assists leadership team in understanding quality and cost control issues related to pharmacy.
 </li>
 <li>
 Works in tandem with Molina Medical Directors to ensure accurate coverage determination decisions.
 </li>
 <li>
 Works with leadership on developing annual training sessions for applicable staff regarding the pharmacy benefit changes for the upcoming year.
 </li>
 <li>
 Works with the Case Management department as part of a member-centered interdisciplinary care team.
 </li>
 <li>
 Works with the PBM to manage formulary changes and update marketing on any changes needed on the web or print versions of the formulary.
 </li>
 <li>
 Performs outreach to patients and physicians as part of quality and/or cost control initiatives.
 </li>
 <li>
 Provides leadership for the pharmacy call center team as delegated by the Manager.
 </li>
 <li>
 Identifies and implements programs to improve clinical outcomes stemming from medication selection, utilization, and adherence.
 
 
 </li>
 </ul>
 
 Job Qualifications
 
 
 
 
 Required Education
 
 
 
 <ul>
 <li>
 Doctor of Pharmacy or bachelor&rsquo;s degree in pharmacy with equivalent experience.
 </li>
 <li>
 Continuing education required to maintain an active pharmacist license.
 
 
 </li>
 </ul>
 
 Required Experience:
 
 1 - 2 years post-graduate experience.
 
 
 
 Required License, Certification, Association:
 
 Active and unrestricted State Pharmacy License for workplace and plan location.
 
 
 
 Preferred Experience
 
 
 
 <ul>
 <li>
 Medicare Part D or Medicaid experience.
 </li>
 <li>
 Managed care experience.
 
 
 </li>
 </ul>
 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.
 
 
 #PJPharm2
 
 
 Pay Range: $80,412 - $156,803.45 / ANNUAL
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 
 
 </li>
 </ul>
</div>

Pharmacist, Prior Auth/Utilization Management, Remote

Molina Healthcare is hiring for a Pharmacist in our UM/Prior Authorization department. Candidates must be licensed to practice in the state of Florida or be able to obtain Florida licensure within 90 days of starting. This position is remote and can be worked from a variety of locations within the US. Shift times can be either 8 or 10 hour shifts between the times of 7a and 10p EST with rotating weekends depending on business needs. Molina Pharmacy Services/Management staff work to ensure that Molina members have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies). KNOWLEDGE/SKILLS/ABILITIES The Pharmacist, UM will be responsible for reviewing coverage determinations and appeals in a timely, compliant, and accurate manner. The Pharmacist, UM will also be responsible for serving as a formulary and drug information resource, assisting technicians and other departments with questions regarding drug coverage. <ul><li>Acts as a liaison between Molina and its customers (members, providers and pharmacies) with respect to the pharmacy benefit.</li><li>Serves as the formulary expert.</li><li>Ensures Molina is compliant with the coverage determination and appeals process.</li><li>Contributes to projects aimed at improving Star ratings, HEDIS, CAHPS, and other quality metrics.</li><li>Assists call center pharmacy technicians with clinical questions and phone calls from prescribers, pharmacies and/or members.</li><li>Develops, implements and maintains pharmacy cost control and quality initiatives under the direction of leadership.</li><li>Monitors drug utilization and assists leadership team in understanding quality and cost control issues related to pharmacy.</li><li>Works in tandem with Molina Medical Directors to ensure accurate coverage determination decisions.</li><li>Works with leadership on developing annual training sessions for applicable staff regarding the pharmacy benefit changes for the upcoming year.</li><li>Works with the Case Management department as part of a member-centered interdisciplinary care team.</li><li>Works with the PBM to manage formulary changes and update marketing on any changes needed on the web or print versions of the formulary.</li><li>Performs outreach to patients and physicians as part of quality and/or cost control initiatives.</li><li>Provides leadership for the pharmacy call center team as delegated by the Manager.</li><li>Identifies and implements programs to improve clinical outcomes stemming from medication selection, utilization, and adherence.</li></ul>JOB QUALIFICATIONS Required Education <ul><li>Doctor of Pharmacy or bachelor&rsquo;s degree in pharmacy with equivalent experience.</li><li>Continuing education required to maintain an active pharmacist license.</li></ul>Required Experience: 1 - 2 years post-graduate experience. Required License, Certification, Association: Active and unrestricted State Pharmacy License for workplace and plan location. Preferred Experience <ul><li>Medicare Part D or Medicaid experience.</li><li>Managed care experience.</li></ul>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. #PJPharm2 #LI-AC1 Pay Range: $80,412 - $156,803.45 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina Healthcare is hiring for remote Certified Pharmacy Technicians. These roles will be in our Prior Authorization department. You will review prior auth requests that are submitted. Schedules for these role will vary between 7am to 10pm EST. Qualified candidates must have either PTCB certification or Pharmacy Tech State license. High preference for those who are self-starters and go-getters. Must have above average computer skills along with a high level of communication skills both written and verbal. As a Pharmacy Tech here at Molina, you will provide support for pharmacy technician activities. You will also contribute to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties <ul><li>Performs initial receipt and review of non-formulary or prior authorization requests against pharmacy plan approved criteria; requests additional information from providers as needed to properly evaluate requests.</li><li>Accurately enters approvals or denials of requests.</li><li>Facilitates prior authorization requests within established pharmacy policies and procedures.</li><li>Participates in the development/administration of pharmacy programs designed to enhance the utilization of targeted drugs and identification of cost-saving pharmacy practices.</li><li>Identifies and reports pharmacy departmental operational issues and resource needs to appropriate leadership.</li><li>Assists Molina member services, pharmacies, and health plan providers in resolving member prescription claims, prior authorizations, and pharmacy service access issues.</li><li>Articulates pharmacy management policies and procedures to pharmacy/health plan providers, Molina staff and others as needed.</li></ul>Required Qualifications <ul><li>At least 2 years pharmacy technician experience, or equivalent combination of relevant education and experience.</li><li>Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice.</li><li>Ability to abide by Molina policies.</li><li>Ability to maintain attendance to support required quality and quantity of work.</li><li>Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA).</li><li>Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.</li><li>Excellent verbal and written communication skills.</li><li>Microsoft Office suite (including Excel), and applicable software program(s) proficiency.</li></ul>#PJPharm3 #LI-AC1 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 Pay Range: $12.19 - $26.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Pharmacy Technician CPhT Prior Auth (Remote)

Join Molina Healthcare and explore 7   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Molina Healthcare

About Company

Senior Data Analyst, Healthcare Analytics

Senior Analyst, Medical Economics - REMOTE

Account Representative, Medicare Sales

Pharmacist, Utilization Management (Remote)

Pharmacist, Prior Auth/Utilization Management, Remote

Pharmacist, Prior Auth/Utilization Management, Remote

Pharmacy Technician CPhT Prior Auth (Remote)