Medical Director (Medicare)

Molina Healthcare • Akron, OH • 3h ago

JOB DESCRIPTION Job Summary

Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

Determines appropriateness and medical necessity of health care services provided to plan members.

Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization.

Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

Assumes leadership 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 investigation of adverse incidents and quality of care concerns.

Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications.

Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams.

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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care.

Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed.

Fosters clinical practice guideline implementation and evidence-based medical practices.

Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management.

Actively participates in regulatory, professional and community activities.

Required Qualifications

At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience.

Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice.

Board certification.

Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.

Ability to work cross-collaboratively within a highly matrixed organization.

Strong organizational and time-management skills.

Ability to multi-task and meet deadlines.

Attention to detail.

Critical-thinking and active listening skills.

Decision-making and problem-solving skills.

Strong verbal and written communication skills.

Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs.

Preferred Qualifications

Experience with utilization/quality program management.

Managed care experience.

Peer review experience.

Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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

Registered Nurse (RN)

Select Medical • Middleburg Heights, OH • 3h ago

Hospital & Medical

Overview Position: Registered Nurse (RN) Location: Regency Hospital - Cleveland West Schedule: PRN/Per Diem $50 per hour Regency Hospital is a critical illness recovery hospital committed to providing world-class inpatie...

3h ago

Go to Apply

Nurse Technician - Oncology

Cleveland Clinic • Akron, OH • 3h ago

Hospital & Medical

Join us at Cleveland Clinic Akron General Hospital where we have been providing world-class care to our community for over 100 years. Cleveland Clinic is recognized as one of the top hospitals in the nation. Here, we str...

3h ago

Go to Apply

Nurse Technician - Neuroscience

Cleveland Clinic • Akron, OH • 3h ago

Hospital & Medical

Join Cleveland Clinic Akron General where we have been providing world-class care to the community for over 100 years. At Akron General, you will work and learn from some of the best caregivers, provide and receive multi...

3h ago

Go to Apply

Staff Nurse: Outpatient Cardiology

CHILDRENS HOSPITAL MEDICAL CENTER OF AKRON • Akron, OH • 2d ago

Hospital & Medical

Outpatient Cardiology Full Time 40 hours/week Days 8a-430p Onsite Summary: The Staff Nurse provides nursing care requiring specialized knowledge judgment and skill derived from the principles of biological, physical, beh...

2d ago

Go to Apply

Medical Assistant I

CHILDRENS HOSPITAL MEDICAL CENTER OF AKRON • Hudson, OH • 2d ago

Hospital & Medical

New Rates of Pay & $2,000 Sign on bonus available Bonus paid in full with first paycheck Full-time, 40 hours/week Variable dayshift Onsite Summary: The Medical Assistant role provides clinical and administrative supp...

2d ago

Go to Apply

AVP, Clinical Operations

Molina Healthcare • Akron, OH • 2d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides strategy and leadership to a team responsible for enterprise clinical operations and program design initiatives. Supports and enables clinicians across Molina to drive desired member...

2d ago

Go to Apply

Occupational Therapist - Outpatient

CHILDRENS HOSPITAL MEDICAL CENTER OF AKRON • Akron, OH • 2d ago

Hospital & Medical

Full-time, 40 hours/weekMonday - Friday, Between hours of 7AM - 6PM & Weekend/holiday rotationOnsite Akron, OH Summary: The Occupational Therapist utilizes professional knowledge and behaviors to evaluate/assess and...

2d ago

Go to Apply

Field Nurse Practitioner (Multiple Openings in CT)

Molina Healthcare • Akron, OH • 3d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides screening, preventive primary care and medical care services to members - primarily in non-clinical settings where members feel most comfortable, including in-home, community and nurs...

3d ago

Go to Apply

Staff Nurse ACHP

CHILDRENS HOSPITAL MEDICAL CENTER OF AKRON • Canton, OH • 3d ago

Hospital & Medical

Full Time (40 hours per week) M-F Days, Start Times Vary Between 7:30am to 9:00am Onsite For Akron Children's Pediatrics Jackson Summary: Provides nursing care and staff guidance for clinical issues, under the direction...

3d ago

Go to Apply

Certified Registered Nurse Anesthetist

CHILDRENS HOSPITAL MEDICAL CENTER OF AKRON • Akron, OH • 3d ago

Hospital & Medical

Summary: This position will collaborate closely with pediatric surgeons, anesthesiologists, and other healthcare providers to assess, plan, and administer anesthesia that is tailored to the unique physiological needs of...

3d 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.