Medical Director (NV)

Molina Healthcare • Omaha, NE • 1d 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

Nurse Anesthetist / Anesthesiology

Omaha Children's Hospital • Omaha, NE • 8h ago

Hospital & Medical

At Children's Nebraska, our mission is to improve the life of every child through exceptional care, advocacy, research and education. As the state's only full-service pediatric healthcare center, we provide comprehensive...

8h ago

Go to Apply

Advanced Practice Nurse Practitioner

Molina Healthcare • Omaha, NE • 8h ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and medical necessity of health care services provided to plan members - targeting improvements in efficiency and satisfaction for m...

8h ago

Go to Apply

Advanced Practice Nurse Practitioner

Molina Healthcare • Bellevue, NE • 9h ago

Hospital & Medical

9h ago

Go to Apply

Advanced Practice Nurse (Nurse Practitioner) - Pulmonary Lung Cancer Coordinator

Veterans Affairs, Veterans Health Administration • Omaha, NE • 2d ago

Hospital & Medical

Summary Omaha VAMC is seeking an Advanced Practice Nurse to be the Clinical Coordinator for the Lung Cancer Screening Program. The Omaha VA is 1 of 14 sites throughout the VA system participating in the Lung Cancer Preci...

2d ago

Go to Apply

Physical Therapist

Catholic Health Initiatives • Omaha, NE • 2d ago

Hospital & Medical

Job Summary and Responsibilities Eligible for up to a $5,000 sign-on bonus and $10,000 in student loan reimbursement!!! As our Inpatient Physical Therapist, you'll help our patients rebuild or maintain their physical wel...

2d ago

Go to Apply

Couples and Partners Driving Team / Mobile Health Technician Team

Health Conservation Incorporated • Omaha, NE • 2d ago

Hospital & Medical

COUPLES AND PARTNERS DRIVING TEAM / MOBILE HEALTH TECHNICIAN TEAM We're Hiring Couples and Partners! POTENTIAL TAKE HOME PAY PER TEAM: UP TO $70,000 ANNUALLY SIGN-ON BONUS FOR NEW DRIVING TEAMS: $5,000.00 per team 100% T...

2d ago

Go to Apply

Substitute Nurse

Glenwood Community School District • Glenwood, IA • 2d ago

Hospital & Medical

Substitute Nurse JobID: 1671 Position Type: Substitute/ Substitute School Nurse Date Posted: 10/29/2025 Location: All - HS, MS, West & NE Elementaries Date Available: 10/29/2025 Closing Date: Until Filled Now accepti...

2d ago

Go to Apply

Pharmacy Technician (Must be state licensed and nationally certified)

Molina Healthcare • Omaha, NE • 3d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides support for pharmacy technician activities. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member...

3d ago

Go to Apply

Pharmacy Technician (Must be state licensed and nationally certified)

Molina Healthcare • Bellevue, NE • 3d ago

Hospital & Medical

3d ago

Go to Apply

Psychiatric Nurse

Catholic Health Initiatives • Omaha, NE • 3d ago

Hospital & Medical

Job Summary and Responsibilities Sign on bonus: Up to $6,000 Provide care for patients through their entire experience Administer medications accurately, safely, and consistently according to the patient's plan of care C...

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.