Director, Operational Oversight (Medicare/Duals) - REMOTE

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 1. 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.

2. 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.

3. 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.

4. 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.

Core Duties 1. 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. 2. Workflow Integration – Embed CTM insights into downstream operations—Stars, appeals & grievances, enrollment, claims—so each team addresses systemic defects. 3. Capabilities Roadmap – Maintain a living roadmap of CTM enhancements; align funding and timelines with IT, Health Plans, and vendor partners. 4. Vendor Performance Validation – Verify that external partners handle CTM complaints per contract and CMS standards; trigger and track remediation when gaps surface. 5. 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. 6. Other Responsibilities – Perform additional assignments as directed by departmental leadership.

Qualifications

Education

• Bachelor’s degree - Health Administration, Business, Information Systems, or related field (advanced degree a plus).

Experience

• 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.

Skills & Competencies

• 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.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Apply Job! Apply to this Job