Medical Director

Molina Healthcare • Tucson, AZ • 1d 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.

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.

Must be able to get additional licensures in multiply states.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Doctorate Degree in Medicine

Board Certified 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

Clinical Nurse Manager

Veterans Affairs, Veterans Health Administration • Tucson, AZ • 5h ago

Hospital & Medical

Summary The Clinical Nurse Manager (CNM) is a professional nurse leader with advanced clinical knowledge and skills and is an integral member of the Nursing, Acute Care Service management team. This position serves under...

5h ago

Go to Apply

Registered Nurse PACT

Veterans Affairs, Veterans Health Administration • Tucson, AZ • 6h ago

Hospital & Medical

Summary The PACT RN is a skilled nurse who is able to work proficiently with some level of supervision to optimize patient care, patient safety and operational efficiency for patients. The focus of the individual's perfo...

6h ago

Go to Apply

Staff Psychologist (BHIP)

Veterans Affairs, Veterans Health Administration • Tucson, AZ • 6h ago

Hospital & Medical

Summary This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP applica...

6h ago

Go to Apply

Registered Nurse

Veterans Affairs, Veterans Health Administration • Tucson, AZ • 8h ago

Hospital & Medical

Summary The Nursing, Acute Care RN is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assumes responsibility for the coordination of care focused...

8h ago

Go to Apply

Certified Hand Therapist - PRN

Select Medical • Tucson, AZ • 18h ago

Hospital & Medical

Overview Position: Certified Hand Therapist (PRN) Location: 265 West Ina Road Tucson, AZ 85704 Schedule: PRN Weekdays - Flexible Schedule Compensation: $50.00 - $55.00/Hr., pending experience Banner Physical Therapy is s...

18h ago

Go to Apply

Physical Therapy Utilization Review Advisor

Sedgwick • Tucson, AZ • 18h ago

Hospital & Medical

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experi...

18h ago

Go to Apply

Physician (GERI PACT)

Veterans Affairs, Veterans Health Administration • Tucson, AZ • 1d ago

Hospital & Medical

1d ago

Go to Apply

Associate Dentist

Dental Business Office • Tucson • 2d ago

Hospital & Medical

We are searching for an enthusiastic and highly skilled dentist to join our practice for full time or part time. We service our patients in a first-class facility with a focus on delivering the highest quality dentistry....

2d ago

Go to Apply

Dental Hygienist

Dental Business Office • Tucson • 2d ago

Hospital & Medical

We are the practice you've been searching for! We are searching for a full or part-time hygienist. We are a patient-centric practice with a focus on building relationships and keeping our patients healthy. All our decisi...

2d ago

Go to Apply

Dental Hygienist

Dental Business Office • Tucson • 2d ago

Hospital & Medical

We are currently seeking a dedicated Dental Hygienist in Tucson, AZ to join our private practice. This is a Full-Time or a part-time position playing a vital role in promoting oral health and keeping our patients healthy...

2d 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.