Director, Operational Oversight (Medicare/Duals) - REMOTE
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Job ** ** Summary
Safeguard member trust and plan compliance by owning Molina’s entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & Resolution you set the standards and controls that internal teams and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances, enrollment, claims, pharmacy, and quality functions.
You surface systemic issues, steer partners toward durable fixes, and convert disciplined CTM management into Stars gains, audit readiness, and measurable member-experience improvements. You’ll begin as a senior individual contributor with the charter to build a focused CTM resolution team as demand grows.
Knowledge, ** ** Skills ** ** & ** ** Abilities
Education
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $88,453 - $172,981 / ANNUAL
Job ** ** Summary
Safeguard member trust and plan compliance by owning Molina’s entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & Resolution you set the standards and controls that internal teams and delegated vendors must follow, and you keep complaint data synchronized across appeals & grievances, enrollment, claims, pharmacy, and quality functions.
You surface systemic issues, steer partners toward durable fixes, and convert disciplined CTM management into Stars gains, audit readiness, and measurable member-experience improvements. You’ll begin as a senior individual contributor with the charter to build a focused CTM resolution team as demand grows.
Knowledge, ** ** Skills ** ** & ** ** Abilities
- CTM Intake & Triage Expertise
- Deep working knowledge of CMS CTM categories, escalation codes, and due-date logic
- Proven history of building—or running—real-time dashboards that keep case aging within SLA
- Demonstrated skill in root-cause triage that routes each complaint to the correct business owner on first touch.
- Resolution Quality & Compliance Mastery
- Track record coordinating cross-functional action plans with Enrollment, Claims, Pharmacy, Network, and Member Services
- Hands-on experience maintaining evidence libraries and template responses for CMS audits and data-validation reviews
- Ability to quantify financial, regulatory, and member-experience risk from complaint trends and to drive prioritized remediation.
- Partner & Vendor Governance
- Experience setting KPIs, SLAs, and governance cadences for delegated entities (TPAs, PBMs, contact centers) that handle CTM work
- Demonstrated success leading joint roadmaps for process upgrades and new CMS requirements—e.g., CTM file-exchange or API integrations
- Solid auditing background: can trace CTM data end-to-end and verify secure, accurate handling by all partners.
- Continuous Improvement & Strategic Leadership
- Proven deployment of pragmatic automation or analytics (AI-ready triage, auto-letter generation) that accelerated resolution without over-engineering
- Documented ability to codify best practices and embed them across multiple lines of business
- Comfortable building business cases and securing resources across IT, Compliance, Quality, and Operations to fund high-return enhancements.
- Case Audits – Run scheduled and ad-hoc audits across internal and delegated platforms to confirm every CTM case is logged, categorized, and resolved within CMS timelines.
- Workflow Integration – Embed CTM insights into downstream operations—Stars, appeals & grievances, enrollment, claims—so each team addresses systemic defects.
- Capabilities Roadmap – Maintain a living roadmap of CTM enhancements; align funding and timelines with IT, Health Plans, and vendor partners.
- Vendor Performance Validation – Verify that external partners handle CTM complaints per contract and CMS standards; trigger and track remediation when gaps surface.
- Innovation & Enablement – Scout regulatory changes and proven technologies (e.g., CTM API integrations, automated acknowledgment letters); pilot and scale solutions that boost accuracy and member experience.
- Other Responsibilities – Perform additional assignments as directed by departmental leadership.
Education
- Bachelor’s degree - Health Administration, Business, Information Systems, or related field (advanced degree a plus).
- 7+ years managing Medicare CTM, appeals & grievances, or related compliance functions—hands-on with CMS CTM portal, SLA tracking, and program audits.
- Deep knowledge of Medicare regulations affecting complaints, grievances, and member communications.
- Exposure to downstream domains: Enrollment, Claims, Pharmacy/PDE, Network, Stars quality metrics.
- Proven record of closing process gaps and delivering durable improvements in a matrixed or vendor-supported environment.
- Mastery of CMS CTM guidelines, escalation protocols, and compliance frameworks.
- Sharp analytical and root-cause skills; comfortable with Excel, SQL/BI, or similar toolsets for complaint trending.
- Persuasive communicator and consensus-builder across health-plan stakeholders and external partners.
- Demonstrated ability to translate regulatory change into road-mapped system and workflow upgrades.
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $88,453 - $172,981 / ANNUAL
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.