Medical Director

Molina Healthcare • Buffalo, NY • 18h 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

Director Financial Services Physician Enterprise

Catholic Health • Buffalo, NY • 2h ago

Hospital & Medical

Salary: 131,098.50-196,657.50 USD Facility: Administrative Regional Training Cntr Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days Hours...

2h ago

Go to Apply

Medical Surgical Nurse

Kaleida Health • Williamsville, NY • 2d ago

Hospital & Medical

Medical Surgical Nurse Department: MFS Nursing 3E Location: Millard Fillmore Suburban Location of Job: US:NY:Williamsville Work Type: Part-Time Scheduled Work Hours: 645am-715pm Shift 1 Job Description Assesses and treat...

2d ago

Go to Apply

Medical Technologist - Plus Sign-On

Labcorp • Buffalo, NY • 2d ago

Hospital & Medical

At Labcorp, we believe in the power of science to change lives. We are a leading global life sciences company that delivers answers for crucial health questions -because we know that knowledge has the potential to make l...

2d ago

Go to Apply

Medical Assistant

Excelsior Orthopaedics Group • Amherst, NY • 2d ago

Hospital & Medical

Job Summary This position works on a clinical operations team providing clinical and clerical support to our providers while ensuring our patients have a safe and positive experience. Duties and Responsibilities Room pat...

2d ago

Go to Apply

Physical Therapist Assistant

Elderwood • Lancaster, NY • 2d ago

Hospital & Medical

Salary $33.00 - $44.86 / hour Overview Don't Look For a Job, Find a Career... Apply today! Benefits for full time employees include: 401K with Employer Matching PTO & Holiday Package Full Suite of Health Benefits - M...

2d ago

Go to Apply

Physical Therapist Assistant

Elderwood • Hamburg, NY • 2d ago

Hospital & Medical

Salary $22.00 - $31.00 / hour Overview At Elderwood, our Mission is People Caring for People. We strive to not only be the partner of choice for our residents, their families and community players - but also for our empl...

2d ago

Go to Apply

Supply Chain Health - Performance Improvement - Senior - Consulting

EY • Buffalo, NY • 4d ago

Hospital & Medical

Location: Anywhere in Country At EY, we're all in to shape your future with confidence. We'll help you succeed in a globally connected powerhouse of diverse teams and take your career wherever you want it to go. Join EY...

4d ago

Go to Apply

MA - Medical Assistant

General Physicians PC • Amherst, NY • 4d ago

Hospital & Medical

25-0619 Amherst, NY, USA Job Description Medical Assistant Who we are : Join General Physician, PC. - one of WNY's largest and most respected multi-specialty medical groups! We are committed to providing comprehensive, h...

4d ago

Go to Apply

Coder Analyst Outpatient HIM MHB

Catholic Health • Buffalo, NY • 5d ago

Hospital & Medical

Salary: 29.23-36.60 USD Facility: Mercy Hospital of Buffalo Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: CWA Local 1133 Exempt from Overtime: Exempt: No Work Schedule: Days Hours: 8:00am - 4:00pm Monda...

5d ago

Go to Apply

Registered Nurse Director of Nursing

Adecco US, Inc. • Buffalo, NY • 5d ago

Hospital & Medical

Are you a proven nursing leader ready to elevate care standards and inspire a high-performing clinical team? We're seeking a dedicated and experienced Director of Nursing (DON) to join our senior leadership team in Buffa...

5d 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.