Medical Director

Molina Healthcare • Davenport, IA • 11h 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.

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

OB Nurse Educator

Trinity Health • Silvis, IL • 8h ago

Hospital & Medical

Employment Type: Full time Shift: 12 Hour Day Shift Description: Nurse Educator - Labor and Delivery Silvis, IL Summary At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of...

8h ago

Go to Apply

Physical Therapist

Trinity Health • Davenport, IA • 18h ago

Hospital & Medical

Employment Type: Part time Shift: Day Shift Description: At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of medical attention. Our Mission is based on improving the health...

18h ago

Go to Apply

Medical Billing Specialist

Robert Half • Davenport, IA • 2d ago

Hospital & Medical

Description Now Hiring: Medical Billing & Front Desk Lead - Quad Cities Join a respected healthcare organization as the Medical Billing & Front Desk Lead! In this role, you'll handle medical billing accuracy, ins...

2d ago

Go to Apply

Pharmacy Department Manager

Hy-Vee Food Stores • Davenport, IA • 4d ago

Hospital & Medical

Additional Considerations (if any): - At Hy-Vee our people are our strength. We promise "a helpful smile in every aisle" and those smiles can only come from a workforce that is fully engaged and committed to supporting o...

4d ago

Go to Apply

Physical Therapy Assistant (PTA) - Per Diem

Select Medical • Davenport, IA • 5d ago

Hospital & Medical

Overview Position: Physical Therapy Assistant (PTA) Location: Davenport, Iowa Compensation: $31.00 Per hour Select Specialty Hospital is a critical illness recovery hospital committed to providing world-class inpatient p...

5d ago

Go to Apply

Medical Assistant- MA: Nephrology

Trinity Health • Davenport, IA • 6d ago

Hospital & Medical

Employment Type: Full time Shift: Day Shift Description: Medical Assistant Location: Davenport Nephrology Clinic Schedule: Dayshift, Monday through Friday, 8 am to 5 pm Summary At MercyOne, health care is more than just...

6d ago

Go to Apply

Physical Therapist - Per Diem

Select Medical • Davenport, IA • 6d ago

Hospital & Medical

Overview Position: Physical Therapist (PT) Location: Davenport, IA Schedule: Per Diem / As Needed / Flexible Schedule Compensation: $53.00 Per Hour Select Specialty Hospital is a critical illness recovery hospital commit...

6d ago

Go to Apply

Acute Care RN - Medical Surgical Registered Nurse

Trinity Health • Silvis, IL • 6d ago

Hospital & Medical

Employment Type: Full time Shift: 12 Hour Day Shift Description: 7:00 am - 7:30 pm, every other weekend Job Posting Title Registered Nurse - Medical/Surgical Silvis, IL Summary At MercyOne, health care is more than just...

6d ago

Go to Apply

Acute Care RN - Medical Surgical Registered Nurse

Trinity Health • De Witt, IA • 6d ago

Hospital & Medical

Employment Type: Full time Shift: 12 Hour Night Shift Description: Weekend Package: Friday, Saturday, Sunday 7pm - 7am Job Posting Title Weekend Package Registered Nurse Medical/Surgical DeWitt, IA Summary At MercyOne, h...

6d ago

Go to Apply

Acute Care RN - Medical Surgical Registered Nurse

Trinity Health • Aledo, IL • 6d ago

Hospital & Medical

Employment Type: Full time Shift: Description: Job Posting Title Registered Nurse Med Surg Aledo, IL Summary At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of medical att...

6d 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.