Director, Delegation Oversight (California Utilization Management) - REMOTE

Job Summary

Leads and directs team responsible for multi-state delegation oversight activities including monitoring of delegation oversight to ensure compliance with state, federal, National Committee for Quality Assurance (NCQA), and Molina requirements. Collaborates closely with internal business owners to manage and administer the relationships and performance of delegated entities including health plan onboarding and offboarding activities, management of oversight activities, audits and corrective action plans, issuance and service issue escalations, and ongoing risk monitoring.

Essential Job Duties

• In collaboration with senior leadership, sets the strategic direction for Molina's delegation oversight responsibilities and partnerships. Responsible for coordinating delegated vendor activities between contracted entities and Molina Healthcare; this includes claims, contact center, credentialing, appeals and grievances, care management, utilization management, pharmacy, and other operational functions across multiple states and lines of business.

Collaborates closely with internal business owners to manage and administer the relationships and performance of delegated entities including health plan onboarding and offboarding activities, management of oversight activities, audits and corrective action plans (CAPs), issuance and service issue escalations, ongoing risk monitoring, and compliance with state, federal, National • Committee for Quality Assurance (NCQA), and Molina requirements.

• Collaborates with internal business partners to develop criteria and best practices for delegated vendor selection, oversight, and management.
• Participates in the negotiation process of delegated service level agreements (SLAs) and addendums; ensures contractual obligations are achieved, and initiates contract changes when required.
• Provides assistance to strategic sourcing, national network, and health plan teams to optimize the cost-effectiveness of negotiations and ensure compliance with regulatory requirements.
• Demonstrates expert review and communications of requirements related to delegated functions - ensuring clarity and minimizing change requests.
• Develops, implements, and manages reporting of metrics and service level agreements (SLAs) that effectively measure team and vendor performance in line with business needs and regulatory compliance.
• Demonstrates deep understanding of business and regulatory requirements, deliverables, processes, and technologies impacting delegated agreements.
• Manages delegated vendor contracts as they relate to specific functions, oversees regulatory requirements, and manages related governance committees, reporting to other applicable committees (e.g., quality).
• Manages delegated vendor relationships as key point of contact between specified vendors and the business.
• Serves as a point of escalation for delegated vendor issues and risks - driving issues to resolution.
• Optimizes delegated vendor relationships through contract management compliance, quantitative analyses, and relationship management - creating mutually beneficial opportunities.
• Maintains tools related to delegation oversight relationships, including delegated vendor tracking, analytics, and performance management.
• Manages the collection, consolidation, and communication of reporting and data on delegated vendor contracts, performance, risk, and relationships with key stakeholders and vendors.
• Manages the performance of national and state delegated vendors to ensure compliance with contractual and regulatory requirements.
• Manages the national delegation oversight performance management team.
• Manages required audits for national and state delegated vendors to ensure compliance with contractual and regulatory requirements.
• Manages national and state delegation oversight audit teams.
• Collaborates with Molina quality department on NCQA external audits to ensure compliance with accreditation standards for applicable national and state delegated vendors.
• Hires, trains, mentors, develops, and manages delegation oversight team, and demonstrates accountability for team performance.

Required Qualifications

• At least 8 years of related delegation oversight/auditing/vendor/data management experience, or equivalent combination of relevant education and experience.
• At least 3 years management/leadership experience.
• Ability to build relationships and manage a team.
• Strong critical-thinking and problem-solving/analytical abilities.
• Strong time-management, organizational, detail orientation and prioritization skills.
• Strong project management skills and knowledge of project management tools/processes.
• Strong data processing/analysis experience.
• Ability to interpret error reports and identify remediation steps.
• Ability to collaborate cross-functionally across a highly matrixed organization.
• Excellent interpersonal and verbal/written communication skills.
• Microsoft Office suite proficiency (including Excel), and ability to learn/navigate new software programs.

Preferred Qualifications

• Experience in Medicaid, Medicare, and Marketplace environments.
• QNXT experience.
• Experience with Power BI and Salesforce (data management).
• Experience with the California Health Plan.
• UM auditing and compliance experience.

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