JOB DESCRIPTION Job Summary Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties • Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. • Researches claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes. • Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. • Meets claims production standards set by the department. • Applies contract language, benefits and review of covered services to claims review process. • Contacts members/providers as needed via written and verbal communications. • Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). • Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. • Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. • Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications • At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. • Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. • Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. • Customer service experience. • Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. • Effective verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. • Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). 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: $16.4 - $31.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job Summary Provides subject matter expertise and leadership for Medicare Stars quality improvement (QI) programs and activities. Provides subject matter expertise in planning and implementing QI initiatives and education programs to support improved Medicare Star ratings. Responsible for leading and managing Medicare Star projects and programs involving enterprise, department, cross-functional and health plan teams of subject matter experts, delivering impactful quality improvement initiatives through design process to completion and outcomes measurement. Essential Job Duties • Collaborates with cross-functional corporate and health plan teams on the development and implementation of enterprise Medicare Stars quality improvement (QI) programs and initiatives across the enterprise. • Manages, plans and executes Medicare Star ratings programs. • Supports Stars program execution and governance needs; communicates, measures outcomes and develops initiatives to improve Star ratings. • Serves as the Medicare Stars subject matter expert to corporate functional areas/health plans, and leads programs to meet critical needs. • Communicates and collaborates with health plans and Stars measure owners to analyze and transform needs and goals into functional requirements to maximize improvement opportunities. • Leads health plan leadership discussions to provide recommendations, performance results and opportunity assessments for Medicare Stars improvement. • Collaborates with operational leaders within the business to provide recommendations on opportunities for process improvements, organizational change management, program management and other processes related to Medicare Star ratings. • Facilitates process improvement, organizational change management, program management and other processes relative to the Medicare Stars Program. • Plans and directs schedules for program initiatives, as well as program budgets. • Develops, defines, and executes plans, schedules, and deliverables; monitors programs from initiation through delivery through outcomes measurement. • Monitors and tracks key performance indicators (KPIs), programs and initiatives to reflect the value and effectiveness of Stars and QI programs. • Creates business requirements documents, test plans, requirements traceability matrix, user training materials and other related documents. • Monitors projects from inception through delivery and outcomes measurement. • May engage and oversee the work of external vendors. • Generates and distributes quality improvement/Medicare Stars standard reports timely. Required Qualifications • At least 6 years of Medicare Stars program and project management experience, or equivalent combination of relevant education and experience. • Demonstrated knowledge of and experience with Medicare Star ratings and QI programs. • Advanced knowledge of the quality discipline, including metrics and performance standards. • Experience with government-sponsored programs (Medicaid, Medicare, Marketplace). • Experience developing performance measures that support business objectives. • Solid business writing experience. • Strong strategic-thinking skills. • Strong proficiency with data analysis, manipulation, interpretation, reporting and data-driven decision-making. • Critical-thinking, problem-solving and analytical skills. • Attention to detail and organizational skills. • Ability to implement process improvement initiatives and drive change. • Ability to work independently in a fast-paced, deadline-driven environment. • Ability to work in a cross-functional highly matrixed organization. • Strong project management experience. • Excellent verbal, written, and presentation communication skills. • Microsoft Office suite (including Excel), and applicable software programs proficiency, and ability to learn new information systems and software programs. Preferred Qualifications • Strong Medicare Stars/quality improvement (QI) program experience. • Six Sigma Black Belt Certification. • ITIL (Information Technology Infrastructure Library) certification. • Experience in leading significant cross-functional work. • Strong project management 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 Pay Range: $65,791.66 - $142,548.59 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Opportunity for TX LVN, LBSW, LMSW to join Molina as a Care Manager working with our Medicaid members in the southern part of the Dallas, TX service delivery area. Communities serviced will be Lancaster, Seagoville, Red Oak, and DeSoto. Responsibilities include completing in-home, face-to-face assessments with our waiver Medicaid members there. Preference will be given to RNs with this type of experience having worked for an MCO organization like Molina. Hours are Monday – Friday, 8 AM – 5 PM CST and mileage is reimbursed as part of our benefit package. Need to be bilingual. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, and Teams as well as being confident in moving between different programs to complete the necessary forms and documentation. Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. • Facilitates comprehensive waiver enrollment and disenrollment processes. • Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. • Assesses for medical necessity and authorizes all appropriate waiver services. • Evaluates covered benefits and advises appropriately regarding funding sources. • Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. • Identifies critical incidents and develops prevention plans to assure member health and welfare. • Collaborates with licensed care managers/leadership as needed or required. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years of health care experience, including at least 1 year of experience working with persons with disabilities/chronic conditions long-term services and supports (LTSS), and 1 year of experience in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements). • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Demonstrated knowledge of community resources. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work independently, with minimal supervision and self-motivation. • Ability to demonstrate responsiveness in all forms of communication and remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Problem-solving skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. • In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications • Certified Case Manager (CCM), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice. • Experience working with populations that receive waiver services. 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: $24 - $46.81 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION This hybrid LPN Care Manager position is based in Miami, Florida , and requires approximately 50% local travel to hospitals and healthcare facilities to support members during critical transitions of care. The ideal candidate will have experience working with the Medicaid population , particularly managing complex, high-risk members with multiple medical, behavioral, and social needs. Candidates should possess strong clinical assessment, care coordination, communication, and problem-solving skills, along with the ability to manage a diverse caseload independently. Bilingual Spanish-English proficiency is preferred to effectively engage and support the diverse communities served throughout the Miami area. Job Summary Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions. • Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network. • Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support. • Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition. • Conducts face-to-face visits of all members while in the hospital and, home visits high-risk members post-discharge as needed. • Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge. • Educates and supports member focusing on seven primary areas (Transition of Care 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 (ICT) and collaboration. • Transition of care coaches with behavioral health and social science education may provide consultation, resources and recommendations to peers as needed. • 40-50% local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, or equivalent combination of relevant education and experience. • Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model. • Background in discharge planning and/or home health. • Demonstrated knowledge of community resources. • Proactive and detail-oriented. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, 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. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Excellent verbal and written communication skills. • Microsoft Office suite/other applicable software program(s) proficiency. Preferred Qualifications • Transitions of care sub-specialty certification and/or Certified Case Manager (CCM). • Hospital discharge planning or home health 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 Pay Range: $24 - $46.81 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Opportunity for TX licensed LVN, LBSW or LMSW residing in the service delivery area of Mercedes and La Feria, TX, to join our LTSS Team as a Case Manager working with our Medicaid members. Part of the responsibilities of the role is to conduct face-to-face meetings with the members in their homes, completing assessments needed for determining the types of services we need to provide. Preference will be given to those candidates with previous LTSS experience. Mileage is reimbursed as part of our benefits package. Hours are Monday – Friday, 8 AM – 5 PM CST. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, and Teams as well as being confident in moving between different programs to complete the necessary forms and documentation. Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. • Facilitates comprehensive waiver enrollment and disenrollment processes. • Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. • Assesses for medical necessity and authorizes all appropriate waiver services. • Evaluates covered benefits and advises appropriately regarding funding sources. • Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. • Identifies critical incidents and develops prevention plans to assure member health and welfare. • Collaborates with licensed care managers/leadership as needed or required. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years of health care experience, including at least 1 year of experience working with persons with disabilities/chronic conditions long-term services and supports (LTSS), and 1 year of experience in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements). • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Demonstrated knowledge of community resources. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work independently, with minimal supervision and self-motivation. • Ability to demonstrate responsiveness in all forms of communication and remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Problem-solving skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. • In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications • Certified Case Manager (CCM), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice. • Experience working with populations that receive waiver services. 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: $24 - $46.81 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Seeking a Florida-licensed behavioral health professional, such as an LCSW, LMSW, APSW, CHES, LPC, LPCC, or LMFT , with experience managing complex behavioral health populations within the Medicaid environment. The ideal candidate will have a strong background in case management and care coordination for members with serious mental illness (SMI) and substance use disorder (SUD) , ensuring seamless transitions of care across inpatient, outpatient, and community-based settings. This role requires expertise in multidisciplinary collaboration, member advocacy, crisis intervention, discharge planning, and connecting members to appropriate behavioral health and community resources to improve outcomes and reduce readmissions. The position includes approximately 10% local travel for member visits, provider collaboration, and care coordination activities. Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes assessments of members per regulated timelines and determines who may qualify for care coordination/care management based on triggers identified in assessments. • Develops and implements care plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • 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. • Collaborates with licensed care managers/leadership as needed or required. • 25- 40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations .• Ability to work independently, with minimal supervision and self-motivation. • Ability to demonstrate responsiveness in all forms of communication, and remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. • In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements). 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: $24 - $46.81 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job Summary Provides support for implementation of health plan provider engagement strategies and activities to drive necessary quality and risk adjustment outcomes. Uses a consultative approach, emphasizing physician engagement and behavior change through actionable data and analytics. Drives value-based care strategies through risk adjustment and quality improvement activities. Focuses on smaller, less advanced Tier 2 and Tier 3 providers, ensuring they have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans. Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitate data exchanges, and supports training and problem resolution for assigned providers - driving provider participation in Molina's risk adjustment and quality initiatives. Essential Job Duties Provides support for provider engagement activities including enhancing value-based strategies, and risk adjustment/quality improvement initiatives. Ensures assigned Tier 2 and Tier 3 providers have a provider engagement plan to meet annual quality and risk adjustment performance goals. Drives provider partner coaching and collaboration to improve Medicaid, Medicare and Marketplace quality performance and risk adjustment accuracy through consistent provider meetings, action item development, and execution. Works with provider front-office staff to get the Molina members with the most open gaps on the schedule seen by their assigned provider. Coordinates with Health Plan Community and Member Engagement resources to drive supporting effort on the member side. Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes. Drives provider participation in Molina risk adjustment and quality efforts (e.g., supplemental data, electronic medical record (EMR) connection, clinical profiles programs) and use of the Molina provider collaboration portal. Tracks all engagement and training activities using standard Molina provider engagement tools to measure effectiveness both within and across Molina health plans. Serves as provider engagement subject matter expert; works collaboratively with health plan and shared service partners to ensure alignment to business goals. Collaborates with assigned health plan Provider Relations Network team member on operational, provider and member issues. Accountable for use of standard Molina Provider Engagement reports and training materials. Develops, organizes, analyzes, documents, and implements processes and procedures as prescribed by health plan and corporate policies. Communicates comfortably and effectively with internal and external stakeholders, including physician leaders, providers, practice managers, and medical assistants within assigned provider practices. Maintains the highest level of compliance. May require same day out-of-office travel up to 80% of the time, depending upon state/health plan requirements. Required Qualifications At least 2 years of experience improving population-level HEDIS quality scores and burden of illness documentation accuracy through provider engagement, or equivalent combination of relevant education and experience. Experience with various managed health care provider compensation methodologies including but not limited to fee-for service (FFS), value-based care (VBC), and capitation. Working knowledge of quality metrics and risk adjustment practices across all business lines. Knowledge and understanding of HEDIS/NCQA and/or CMS STARs quality measures and risk adjustment practices across Medicaid, Medicare, and Marketplace Proficiency with data analysis, manipulation, interpretation, and reporting. Critical-thinking, problem-solving, and analytical skills. Relationship building skills. Attention to detail and organizational skills. Ability to implement process improvement initiatives and drive change. Ability to work independently in a fast-paced, deadline-driven environment. Ability to foster and build relationships in a cross-functional highly matrixed organization to obtain buy-in and drive results. Effective verbal and written communication skills. Microsoft Office suite (including Excel), Power BI, and other applicable software programs proficiency, and ability to learn new information systems and software programs. Preferred Qualifications Bachelor’s degree in Nursing, Health Administration or relevant discipline. Solid understanding of health insurance, provider messaging/design, and project management Strong experience using Microsoft products, including Excel (knowledge of pivot tables, VLOOKUP, etc.) and PowerPoint 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: $45,390 - $80,511.46 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. 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: $26.41 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Provides support for community-based member advocacy activities. Serves as a local member advocate and resource, using knowledge of the community and resources available to engage and assist vulnerable members in managing health care needs. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Engages with members as an advocate and resource to support management of health care needs. • Collaborates with and supports the health care services team by providing non-clinical paraprofessional duties in the field to include meeting with members in their homes, nursing homes, shelters, provider offices, etc. • Empowers members by helping them navigate and maximize their health plan benefits. Assistance may include: scheduling appointments with providers, arranging transportation for health care visits, getting prescriptions filled and following-up with members on missed appointments. • Assists members in accessing social services such as community-based resources for housing, food, employment, etc. • Provides outreach to locate and/or provide support for disconnected members with special needs. • Conducts research with available data to locate members that Molina has been unable to contact (e.g., reviewing internal databases, contacting member providers or caregivers or travel to last known address or community resource locations such as homeless shelters, etc.) • Participates in ongoing or project-based activities that may require extensive member outreach (telephonic and/or face-to-face). • Guides members to maintain Medicaid eligibility and with other financial resources as appropriate. • 50% local travel required in and around the Pulaski County areas (based upon state/contractual requirements). Required Qualifications• At least 1 year of health care experience, preferably working with underserved or special needs populations with varied health, economic and educational circumstances, or equivalent combination of relevant education and experience. • Community Health Worker (CHW) certification may be required for certain states (dependent upon contractual requirements). • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Ability to multi-task applications while speaking with members. • Excellent customer service skills. • Organizational and time-management skills. • Ability and willingness to learn other lines of business, programs and relevant software systems/applications. • Excellent verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Community Health Worker (CHW) certification (for states other than Ohio, Florida and California, where it is required). • Certified Medical Assistant (CMA). • Bilingual based on community need. • Familiarity with health care systems. • Knowledge of community-specific culture. • Experience with/or knowledge of health care systems, community resources, social services, and/or health education. 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: $15.58 - $31.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job Summary Provides strategy and leadership to team responsible for provider network management, operations, and contracting activities . Leads network strategy and development with respect to adequacy, financial performance, and operational performance. Develops network standards and resources designed to enable Molina to establish and maintain distinct high-performing networks of compassionate and culturally sensitive providers aligned with Molina's mission, vision and values. Essential Job Duties • Supports strategy development, vision and direction for the network function. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised. • Develops and implements provider network and contract strategies in new Molina markets - identifying specialties and geographic locations to concentrate resources for the purpose of establishing a sufficient network of participating providers to serve the health care needs of Molina's membership and meet established financial goals. • Develops and maintains a market-specific provider reimbursement strategies consistent with reimbursement tolerance parameters (across multiple specialties/geographies). • Oversees the development of new reimbursement models; facilitates communication, oversight and approval processes for health plan exceptions for all lines of business. Develops and enhances the provider network management and operations function including the implementation of standard processes, policies and procedures. • Develops a standardized provider engagement “tool kit”, training program and deployment plan.; develops and implements approaches to determining outcomes of tools and training programs. • Collaborates closely with health plans leadership to ensure compliance with all Molina, regulatory and industry standards. • Supports and executes new health plan implementations, acquisitions and expansions in collaboration with the business development team. • Collaborates with senior leadership, health plan leadership, and collaborating functions to develop and implement provider contracting strategies and provider service strategies to contain unit cost, improve member access and enhance provider satisfaction enterprise-wide. • Develops and oversees deployment strategy and monitoring for “provider profiles” and “pay-for-performance (P4P)” contracting. • In conjunction with provider services and provider contracting leaders in the health plans and within the corporate function, develops and implements approaches for performance management of value-based reimbursement. • Develops and refines “clear coverage” provider adoption strategies and assists in training of health plan staff as clear coverage is implemented in each plan. • Represents provider engagement with stakeholder experience, quality and RAMP business partners to ensure incorporate of necessary plans to achieve positive operational and financial outcomes. • Develops and maintains a system to track contract negotiation activities; facilitates health plan implementation, utilization, compliance, and develops and delivers enterprise-wide training for the contract management system. • Develops and authors all enterprise contract templates in conjunction with legal; disseminates templates, and maintains and updates to include state regulatory changes, operational business objectives and financial terms; maintains language libraries for the enterprise. • Directs the strategy, preparation and negotiations of national provider contracts across the enterprise; oversees negotiation of national contracts in concert with established company templates and guidelines with vendors, physicians, hospitals, and other health care providers. • Monitors key metrics to determine provider engagement effectiveness and success (e.g. provider appeals and grievances, member appeals and grievances, Consumer Assessment of Healthcare Providers and Systems (CAHPs), STAR ratings, Healthcare Effectiveness Data Information Set (HEDIS), HEP completion Rates, etc.) • Leads and manages the development and implementation of activities for network development and contracting projects. • Directs the evaluation, review, and negotiation processes for network development projects. • Supports business development and new business implementation engagements across markets, taking into consideration individual market circumstances, provider community, budget guidelines and available resources. • Completes negotiations with complex and major provider contracts as needed to support network objectives. • Leads the network development and contracting teams during the development and implementation stages. • Monitors performance in accordance with Molina standards and guidelines; communicates with senior leadership and other Molina leaders regarding network strategy and planning. • Contributes as a key member of the corporate network leadership team. • Hires, trains, manages and evaluates team member performance - provides coaching, development, and recognition; ensures ongoing appropriate staff training, holds regular team meetings, and drives communication and collaboration. • Develops and sustains a high-performance team, dedicated to best in class solutions; responsible for attracting, developing and retaining top-tier talent to support strategy and long-term business objectives. Required Qualifications • At least 10 years of experience in health care to include experience in provider network management/contracting, health care operations, and/or government-sponsored programs, and at least 8 years of senior level network operations experience, or equivalent combination of relevant education and experience. • At least 5 years of management/leadership experience. • Extensive experience in the health insurance industry. • Track record of strong relationships with hospitals, provider groups, and independent physician associations (IPAs). • Expert level knowledge regarding reimbursement methodologies across all lines of business (Medicaid, Medicare, Marketplace). • Strong experience with various managed health care provider compensation methodologies. • Excellent negotiation and relationship building capabilities. • Ability to navigate complex regulatory environments. • Strong data-driven decision-making skills, and analytical abilities. • Strong organizational skills and attention to detail. • Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization, and influence business decisions. • Ability to manage multiple tasks and deadlines effectively. • Strong project management skills. • Excellent verbal and written communication skills, and ability to present at an executive level. • Microsoft Office suite and applicable software programs proficiency. 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: $161,914.25 - $315,732.79 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.