Medical Director

Molina Healthcare • Utah, Utah • 4d ago

JOB DESCRIPTION

Job Summary

Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.

MD licenses required for the following states: WA FL, MI, MS, NM, KY, TX, CA, IL, OH, ID, SC, UT, WI, AZ, MA, NV, IA, GA

Job Duties

Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as 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.

Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.

Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.

Facilitates conformance to Medicare, Medicaid, 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, 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 the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.

Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Doctorate Degree in Medicine

Board Certified or eligible in a primary care specialty

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

3+ years relevant experience, including:

2 years previous experience as a Medical Director in a clinical practice.

Current clinical knowledge.

Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

Knowledge of applicable state, federal and third party regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.

PREFERRED EDUCATION:

Master's in Business Administration, Public Health, Healthcare Administration, etc.

PREFERRED EXPERIENCE:

Peer Review, medical policy/procedure development, provider contracting experience.

Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

Experience in Utilization/Quality Program management

HMO/Managed care experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Board Certification (Primary Care preferred).

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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 - $315,733 / ANNUAL

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

Similar Jobs

Medical Assistant I

University of Utah Health • Salt Lake City, UT • 1h ago

Hospital & Medical

Overview As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of coll...

1h ago

Go to Apply

Medical Assistant I

University of Utah Health • Salt Lake City, UT • 1h ago

Hospital & Medical

1h ago

Go to Apply

Medical Assistant I

University of Utah Health • Stansbury Park, UT • 1h ago

Hospital & Medical

1h ago

Go to Apply

Medical Assistant I

University of Utah Health • Salt Lake City, UT • 1h ago

Hospital & Medical

1h ago

Go to Apply

Medical Technician

U.S. Military Entrance Processing Command • Salt Lake City, UT • 2h ago

Hospital & Medical

Summary About the Position: This is a Direct Hire Authority (DHA) solicitation utilizing the DHA for Certain Personnel of the Department of Defense Workforce to recruit and appoint qualified candidates to positions in th...

2h ago

Go to Apply

Physical Therapist PRN

Intermountain Health • Hurricane, UT • 5h ago

Hospital & Medical

Job Description: This position is responsible for screening, testing, evaluating, diagnosing and treatment of injuries, diseases, and disabilities using physical therapy procedures and modalities in accordance with stand...

5h ago

Go to Apply

Physical Therapist Assistant PRN

Intermountain Health • Cedar City, UT • 5h ago

Hospital & Medical

Job Description: The Physical Therapist Assistant provides assistance to the physical therapist in developing and implementing physical therapy treatment, procedures, and related activities for direct patient care. In ad...

5h ago

Go to Apply

Entry Level Hospital Services Technician

WM • North Salt Lake, UT • 11h ago

Hospital & Medical

$20.19/hr 5AM Start Time NO WEEKENDS and Great Benefits About Us: Stericycle is now part of WM!!! To learn more about WM's acquisition of Stericycle, CLICK HERE ( https://investors.wm.com/news-releases/news-release-detai...

11h ago

Go to Apply

Nurse

Prevent Child Abuse Utah • Salt Lake City, UT • 20h ago

Hospital & Medical

Are you a nurse looking for an amazing opportunity to change the lives of families? Do you want a job with a flexible schedule? This might be the job for you! Please review these two links before applying: https://www.yo...

20h ago

Go to Apply

Nurse

Prevent Child Abuse Utah • Saint George, UT • 20h ago

Hospital & Medical

20h 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.