Medical Director

Molina Healthcare • Phoenix, AZ • 9h 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

REQU IRED ED UC ATI ON :

Doctorate Degree in Medicine

Board Certified or eligible in a primary care specialty

REQU IRED E XPE RI EN CE/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

REQU IRED L IC EN SE, CE RTI FI CA TI ON , AS SO CI ATI ON :

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

PR EFE RRED ED UC ATI ON :

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

PR EFE RRED E XPE RI EN CE:

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

PR EFE RRED L IC EN SE, CE RTI FI CA TI ON , AS SO CI ATI ON :

Board Certification (Primary Care preferred).

PHY SI CAL DEM AN DS :

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

Associate Territory Manager - Medical Imaging - 38

Rep-Lite • Phoenix, AZ • 43min ago

Hospital & Medical

Associate Territory Manager - Medical Imaging (Entry-Level Sales Track) About Us Rep-Lite partners with the world's top medical technology companies to launch and grow sales talent in the field. We're representing a glob...

43min ago

Go to Apply

Pharma & MedTech Supply Chain - End to End, Senior Associate

PwC • Phoenix, AZ • 48min ago

Hospital & Medical

Specialty/Competency: Operations Industry/Sector: Pharma and Life Sciences Time Type: Full time Travel Requirements: Up to 60% At PwC, our people in operations consulting specialise in providing consulting services on op...

48min ago

Go to Apply

Nurse Urgent Care

Dignity Health • Chandler, AZ • 54min ago

Hospital & Medical

Job Summary and Responsibilities As an Urgent Care Nurse at Dignity Health, now part of CommonSpirit Health formed between Catholic Health Initiatives (CHI) and Dignity Health, you'll be the first touchpoint to the peopl...

54min ago

Go to Apply

Medical Director

Molina Healthcare • Scottsdale, AZ • 8h ago

Hospital & Medical

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 th...

8h ago

Go to Apply

Medical Director

Molina Healthcare • Mesa, AZ • 9h ago

Hospital & Medical

9h ago

Go to Apply

Medical Director

Molina Healthcare • Chandler, AZ • 9h ago

Hospital & Medical

9h ago

Go to Apply

Account Director, Medical Education & Communications

IQVIA • Phoenix, AZ • 18h ago

Hospital & Medical

Account Director, Medical Education & Communications Position Overview MedForce, an IQVIA business, provides best-in-class medical communication services to help life sciences companies connect with HCPs - and improv...

18h ago

Go to Apply

Account Director, Medical Education & Communications

IQVIA • Mesa, AZ • 18h ago

Hospital & Medical

18h ago

Go to Apply

Abstraction Partner Non-Clinical

Intermountain Health • Phoenix, AZ • 18h ago

Hospital & Medical

Job Description: Professional clinical data abstractors/registrar support the on-going work of performance improvement through the enterprise by performing high-quality data abstraction, compilation, validation, for clin...

18h ago

Go to Apply

Physical Therapist Assistant

U.S. Physical Therapy • Phoenix, AZ • 19h ago

Hospital & Medical

Company Description Desert Hand and Physical Therapy opened its doors in 1997 with one therapist and an office manager, who shared common goals of providing patients with the best and most qualified upper-extremity care...

19h 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.