Medical Director

Molina Healthcare • Albany, NY • 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 Nurse Manager

Ellis Medicine • Clifton Park, NY • 52min ago

Hospital & Medical

Basic Function: The Associate Nurse Manager functions as the clinical manager of a unit for an assigned shift. Provides support to the nurse manager in the planning, education, coordination, staffing, and supervision of...

52min ago

Go to Apply

Abstraction Partner Non-Clinical

Intermountain Health • Albany, NY • 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

Lead Physical Therapist - St. Peter's Hospital

Trinity Health • Albany, NY • 19h ago

Hospital & Medical

Employment Type: Full time Shift: Day Shift Description: Lead Physical Therapist - St. Peter's Hospital Great Leadership opportunity for an experienced Physical Therapist with inpatient acute experience! Highlights: Reco...

19h ago

Go to Apply

Administrative Liaison - Outpatient Surgical Office - Troy - FT

Trinity Health • Troy, NY • 22h ago

Hospital & Medical

Employment Type: Full time Shift: Day Shift Description: Administrative Liaison - Outpatient Vascular Surgery Office - Troy, NY The Administrative Liaison will split its time between surgical scheduling and administrativ...

22h ago

Go to Apply

RN - Home Health

EGA Associates • Albany, NY • 23h ago

Hospital & Medical

Details Client Name: New York State Office for People with Developmental Disabilities (OPWDD) Job Type: Local Position Urgency Normal Offering Nursing Profession RN Specialty Home Health Job ID 17277622 Shift Details Shi...

23h ago

Go to Apply

Evening Registered Nurse

Together For Youth • Albany, NY • 1d ago

Hospital & Medical

Job Details[TABLE]Join Our MissionAs a Secure Detention RN at Berkshire, you will be responsible for providing an initial health assessment of youth entering the facility including but not limited to health history, phys...

1d ago

Go to Apply

Nurse - LPN

Northern Rivers Family Services • Albany, NY • 1d ago

Hospital & Medical

Nurse - LPN Job Details Job Location Albany-New Karner-NPCS - Albany, NY Position Type Full Time Salary Range $27.00 - $28.00 Hourly Travel Percentage Up to 50% Description As a Licensed Practical Nurse, you will coordin...

1d ago

Go to Apply

Oracle Health Learning Leader

Oracle • Albany, NY • 1d ago

Hospital & Medical

Job Description PLEASE NOTE: THIS ROLE REQUIRES UP TO 75% TRAVEL. CANDIDATE MUST BE A US CITIZEN AND BE ABLE TO OBTAIN SECURITY CLEARANCE. As a Learning Leader on the Federal Learning team, you will be responsible for th...

1d ago

Go to Apply

Consultant, Behavioral Health I

Lincoln Financial • Albany, NY • 1d ago

Hospital & Medical

Alternate Locations: Charlotte, NC (North Carolina); Omaha, NE (Nebraska); Work from Home Work Arrangement: Remote : Work at home employee residing outside of a commutable distance to an office location. Relocation assis...

1d ago

Go to Apply

Representative, Medication Therapy Management Services (Remote)(Bilingual)

Molina Healthcare • Albany, NY • 2d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides customer service support for inbound/outbound Medication Therapy Management (MTM) pharmacy calls from members, providers, and pharmacies. Contributes to overarching pharmacy strategy...

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.