Jobs at Molina Healthcare Inc.

Supports vulnerable health plan members through community-based advocacy and nonclinical care navigation. Helps members schedule appointments, arrange transportation, fill prescriptions, access social services, maintain Medicaid eligibility, and reconnect with care teams. Conducts outreach in homes and community settings, researches contact information, and collaborates with healthcare services staff. The role requires extensive local travel, strong communication and organizational skills, and familiarity with community resources and healthcare systems.

Organizes healthcare claims, utilization, provider, and enrollment data to create recurring and ad hoc reports, dashboards, reconciliations, and analytical summaries. Identifies data-quality and process gaps, supports regulatory inquiries and cross-functional projects, tracks reporting deliverables, and translates complex healthcare data into actionable insights for business performance, cost containment, utilization, and compliance improvements.

Supervises eligibility screeners supporting long-term care functional screening for older adults and adults with disabilities. Responsibilities include hiring, training, coaching, quality oversight, resolving screening issues, completing LTCFS assessments, coordinating with stakeholders, supporting fair hearings, maintaining regulatory compliance and certification, improving processes, and preparing reports. The role requires local travel to member locations and monthly attendance at a Molina office.

Examines complex healthcare claims to identify coding errors, fraud, abuse, waste, overpayments, and processing defects. Manages claim caseloads, obtains medical records, monitors claimant treatment, recommends investigations and resolutions, ensures regulatory compliance, and supports claims process improvement initiatives while meeting quality and production standards.

Supports vulnerable members with navigating health care benefits, scheduling appointments, arranging transportation, obtaining prescriptions, and accessing social services. Conducts outreach through phone and field visits to homes, shelters, nursing homes, and provider offices. Helps members maintain Medicaid eligibility, researches hard-to-reach members, and collaborates with health care teams. The role requires local travel, strong communication and organizational skills, reliable transportation, and at least one year of health care experience.

Supports Wisconsin IRIS participants with long-term care planning, community resources, budgets, documentation, compliance, and self-directed services. Builds trusting relationships, conducts participant visits, coordinates providers and fiscal agencies, develops individualized plans, monitors outcomes, and helps participants navigate employment, housing, health, safety, transportation, and community goals. The role is remote but requires regular community visits, in-person team meetings, and travel throughout the service area.

Leads healthcare compliance strategy and operations, ensuring adherence to regulatory requirements, industry standards, internal policies, and anti-fraud controls. Oversees Medicaid and CMS audits, investigations, regulatory relationships, delegation oversight, compliance planning, training, reporting, and risk mitigation. Advises executives and boards, manages compliance programs, and leads cross-functional teams in a highly regulated health plan environment.

Leads application engineering teams delivering cloud-native, AI-enabled solutions on Microsoft Azure for Medicare and Medicaid claims-processing operations. Oversees architecture, software development, quality automation, integrations, support, governance, security, vendor relationships, and large-scale implementations. Develops Azure applications as needed, mentors staff, manages cross-functional initiatives, ensures HIPAA compliance, and partners with business and executive stakeholders to improve healthcare payer outcomes.

Supports health plan member growth and retention through eligibility assistance, recertification outreach, application processing, issue resolution, care-gap closure, appointment scheduling, and member education. Documents interactions, manages state dashboards, promotes plan programs, supports renewal events, and collaborates on improvements to member experience and retention. Some in-office training, meetings, and community-based field work are required.

Leads a field-based benefit sales and enrollment team, develops regional business plans, drives membership growth, manages strategic relationships, conducts sales coaching, oversees market research and partnerships, and ensures compliance with CMS and state regulations. Responsible for hiring, training, performance management, sales targets, enrollment growth, provider engagement, and travel throughout assigned territories.

Provides executive leadership for healthcare provider network strategy, operations, contracting, reimbursement models, and financial performance. Oversees provider negotiations, network adequacy, contract administration, fee schedules, delegation oversight, provider services, appeals, and regulatory compliance. Builds relationships with hospitals, physician groups, and IPAs while leading profitable network growth. Manages and develops a high-performing team and collaborates with executive, legal, corporate, and cross-functional stakeholders.

Evaluates and adjudicates complex healthcare claims to identify coding errors, fraud, waste, overpayments, abuse, and processing issues. Manages claim caseloads, obtains medical records, monitors treatment, maintains documentation, recommends investigations and resolutions, and supports defect reduction and process improvement. Ensures compliance with state and federal regulations, turnaround times, quality standards, and department initiatives across multiple lines of business.

Leads healthcare program and project delivery across multiple workstreams, managing scope, timelines, stakeholders, budgets, governance, risks, and dependencies. Analyzes dashboards, reports, operational metrics, and large datasets to identify performance gaps and recommend improvements. Develops policies, workflows, playbooks, business requirements, test plans, and training materials. Drives change management, provider engagement, quality improvement, compliance, reporting, and issue resolution across cross-functional teams.

Leads large-scale quality systems and analytics programs across a complex, regulated healthcare organization. Responsibilities include program design and delivery, governance, portfolio and project management, process improvement, change management, budgeting, performance reporting, stakeholder engagement, documentation, business requirements, testing, training, and cross-functional collaboration with legal, compliance, and IT teams.

Manages multiple Appeals and Grievances projects from inception through delivery, overseeing scope, schedules, resources, budgets, quality, stakeholders, and change management. Develops project plans, status reports, process documentation, SOPs, workflows, and PEGA job aids. Coordinates process improvements, governance changes, vendors, training, and cross-functional collaboration with executive, operational, and PEGA teams across multiple regions.

Supports Wisconsin IRIS participants with long-term care planning, community resource coordination, budgeting, compliance, documentation, and navigating employment, housing, health, safety, transportation, and community goals. Builds trusting relationships, conducts required in-person visits, provides program orientation, coordinates with fiscal and agency partners, tracks plan changes, and maintains HIPAA confidentiality while working independently and collaboratively.

Conducts home-based Wisconsin long-term care functional screening assessments for older adults and adults with physical or intellectual disabilities. Schedules and completes assessments, coordinates with members, families, and interdisciplinary care teams, tracks screening deadlines, maintains accurate documentation, supports quality assurance, and stays current on certification and state requirements. Requires local travel, strong communication, data management, training, and professional judgment.

Examines healthcare claims to identify coding errors, fraud, waste, overpayments, and processing defects. Manages claim caseloads, obtains supporting medical records, recommends investigations or resolutions, identifies pre-payment issues, and supports process-improvement initiatives while meeting quality and productivity standards.

Provides senior engineering support for enterprise infrastructure and ServiceNow-enabled platforms across hybrid cloud, compute, storage, networking, databases, and automation. Leads complex deployments, configuration, monitoring, troubleshooting, security remediation, architecture reviews, and technical workstreams. Uses Azure, PowerShell, Python, Terraform, SQL, and observability tools to improve reliability and scalability. Collaborates with cross-functional teams, supports compliance and change management, mentors engineers, contributes to strategic roadmaps, and participates in on-call support.

Manages regional delegation oversight across multiple states, ensuring delegated entities comply with state, federal, NCQA, and organizational requirements. Oversees audits, corrective action plans, risk monitoring, regulatory documentation, committee meetings, performance reporting, and entity onboarding or offboarding. Leads a delegation oversight team by hiring, training, mentoring, and managing performance while collaborating with internal stakeholders and senior leadership.