Advanced Practice Nurse Practitioner

Molina Healthcare • Grand Rapids, MI • 1d ago

JOB DESCRIPTION Job Summary

Provides medical oversight and expertise in appropriateness and medical necessity of health care services provided to plan members - targeting improvements in efficiency and satisfaction for member patients and providers, in addition to meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

Demonstrates and facilitates conformance to Medicare, Medicaid, National Committee for Quality Assurance (NCQA) and other regulatory requirements.

Reviews quality referred issues, focused reviews and recommends corrective actions.

Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and others as directed by the chief medical officer.

Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process.

Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.

Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

Develops and implements plan medical policies.

Provides implementation support for quality improvement activities.

Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions if needed.

Collaborates with contracting department in contract negotiations.

Fosters clinical practice guideline implementation and evidence-based medical practices.

Utilizes information technology and data analysts to produce tools to report, monitor and improve utilization management.

Actively participates in regulatory, professional and community activities.

Required Qualifications

At least 8 years of health care experience, including 5 years of clinical practice experience, 3 years utilization/quality program management experience, and 2 years managed care experience, or equivalent combination of relevant education and experience.

Advanced Practice Registered Nurse (APRN) license. License must be active and unrestricted in the state of practice.

Current clinical knowledge.

Ability to work within a variety of settings and adjust style as needed - working with diverse populations and 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.

Excellent time-management and prioritization skills; ability to focus on multiple projects simultaneously and adapt to change.

Excellent problem-solving and critical-thinking skills.

Ability to work in a high-pressure environment.

Ability to maintain attendance to support required quality and quantity of work.

Ability to maintain confidentiality and comply with health insurance portability and accountability act (HIPAA).

Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Knowledge of applicable state, federal and third party regulations.

Strong verbal and written communication skills.

Microsoft Office proficiency, and ability to navigate an electronic medical record (EMR) system.

Preferred Qualifications

Board certification (primary care preferred).

Peer review, medical policy/procedure development, and/or provider contracting experience.

Experience with National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data Information Set (HEDIS), Medicaid, Medicare and Pharmacy Benefit Management (PBM), Group/IPA practice, capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines.

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: $117,731 - $275,491 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

Cleaning- Medical, Office or Manufacturing Setting

Enviro-Clean Services, Inc • Grand Rapids, MI • 3h ago

Hospital & Medical

Join Our Team in the Grand Rapids Area! We're hiring dedicated individuals to help create clean, welcoming spaces. Whether you're seeking a fresh start or the next step in your career, we've got a role for you! Open Posi...

3h ago

Go to Apply

Cleaning- Medical or Medical Manufacturing Setting

Enviro-Clean Services, Inc • Kentwood, MI • 3h ago

Hospital & Medical

Join Our Team in the Kentwood Area! We're hiring dedicated individuals to help create clean, welcoming spaces. Whether you're seeking a fresh start or the next step in your career, we've got a role for you! Open Position...

3h ago

Go to Apply

Professional Lab and Compliance Coordinator-Nursing

Davenport University • Grand Rapids, MI • 3h ago

Hospital & Medical

Professional Lab and Compliance Coordinator-Nursing Professional Lab and Compliance Coordinator-Nursing STATUS: Temporary, Part Time: January 2026 - June 30th 2026, $13,585 DEPARTMENT: Academics LOCATION: Warren Michigan...

3h ago

Go to Apply

Adjunct Faculty-Midland-Clinical Faculty: Mental Health

Davenport University • Grand Rapids, MI • 16h ago

Hospital & Medical

Adjunct Faculty-Midland-Clinical Faculty: Mental Health Who we are: Davenport University is a private, non-profit university focused on offering a practical curriculum and the latest degree programs. Our graduates are pr...

16h ago

Go to Apply

Account Representative Patient Accounts Full Time

Pine Rest Christian Mental Health Services • Grand Rapids, MI • 1d ago

Hospital & Medical

Cost Center 923 Patient Accounts Scheduled Weekly Hours 40 Work Shift First Shift (United States of America) Shift & Status Who Are We? We at Pine Rest believe in the power of healing and that everyone in our communi...

1d ago

Go to Apply

Medical Director (NV)

Molina Healthcare • Grand Rapids, MI • 2d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and pr...

2d ago

Go to Apply

Adjunct Faculty - Nursing

Grand Rapids Community College • Grand Rapids, MI • 3d ago

Hospital & Medical

Adjunct Faculty - Nursing Department: Nursing Program Location: Grand Rapids, MI Grand Rapids Community College department of https://www.grcc.edu/schools-departments/nursing-programs is seeking a dynamic and dedicated A...

3d ago

Go to Apply

Clinical Informatics Specialist 2-Information Technology

University of Michigan Health-West • Grand Rapids, MI • 3d ago

Hospital & Medical

University of Michigan Health-West (Formally Metro Health) is looking for a Clinical Informatics Specialist 2-Information Technology The Clinical Informatics Specialist (CIS) is responsible for participating in the plann...

3d ago

Go to Apply

Cleaning- Medical or Medical Manufacturing Setting: $16.00- $25.00 (Janitorial)

Enviro-Clean • Kentwood, MI • 3d ago

Hospital & Medical

Cleaning- Medical or Medical Manufacturing Setting: $16.00- $25.00 (Janitorial) Kentwood, MI, United States of America $16.00 - $25.00 Back Apply Now Back Apply Now Overview Job Skills / Requirements Join Our Team in the...

3d ago

Go to Apply

Cleaning- Medical, Office or Manufacturing Setting: $16.00- $18.00 (Janitorial)

Enviro-Clean • Grand Rapids, MI • 3d ago

Hospital & Medical

Cleaning- Medical, Office or Manufacturing Setting: $16.00- $18.00 (Janitorial) Grand Rapids, MI, United States of America $16.00 - $18.00 Back Apply Now Back Apply Now Overview Job Skills / Requirements Join Our Team in...

3d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.