Medical Director (Medicare)

Molina Healthcare • Texas, Texas • 6d 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

PJHS

LI-AC1

Pay Range: $186,201.39 - $363,093 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

Pharmacy Operations Manager

Walgreens • Flower Mound, TX • 4h ago

Hospital & Medical

Job Description: Where state and federal laws/regulations allow, accountable for performing day-to-day non-clinical pharmacy operations, administrative activities; Ensures efficient pharmacy workflow and a positive patie...

4h ago

Go to Apply

Medical Assistant

Actalent • Pearland, TX • 4h ago

Hospital & Medical

Job Title: Medical Assistant Job Description We are seeking a dedicated Medical Assistant for a dynamic role that involves floating between back office, front office, and surgery scheduling tasks. This position is integr...

4h ago

Go to Apply

Medical Assistant

Adecco US, Inc. • McKinney, TX • 4h ago

Hospital & Medical

Adecco Healthcare & Life Sciences is working with our client in McKinney, TX to hire Medical Assistants (2) for their facility. These positions are in-person and on-site. Type: Contract to Hire Hours: 8a-5p Pay Range...

4h ago

Go to Apply

Medical Assistant

CenterWell • Dallas, TX • 4h ago

Hospital & Medical

Become a part of our caring community and help us put health first The Medical Assistant is the first point of contact for patient care. Responsible for administrative duties in addition to patient care. The Medical Assi...

4h ago

Go to Apply

Medical Biller

Prime Healthcare • Mesquite, TX • 4h ago

Hospital & Medical

Overview We are seeking a Medical Biller , sometimes referred to as a Hospital Billing Specialist, Patient Accounts Representative or Insurance Billing Specialist. As our Medical Biller, you will manage patient billing a...

4h ago

Go to Apply

Medical Receptionist

U.S. Physical Therapy • Carrollton, TX • 4h ago

Hospital & Medical

Company Description Green Oaks Physical Therapy (GOPT) has provided exceptional outpatient orthopedic care in the DFW metroplex for twenty-five years! Founded by Physical Therapists in 2000, GOPT now has 17 locations, al...

4h ago

Go to Apply

Medical Assistant

Adecco US, Inc. • Fort Worth, TX • 4h ago

Hospital & Medical

Adecco Healthcare & Life Sciences is hiring Medical Assistants in Fort Worth, Texas! This role is in person / onsite. Please review the details below and reply with an updated resume. Position Type : Three-month cont...

4h ago

Go to Apply

Medical Assistant

CenterWell • New Braunfels, TX • 4h ago

Hospital & Medical

4h ago

Go to Apply

Medical Assistant

University of Texas Rio Grande Valley • Edinburg, TX • 4h ago

Hospital & Medical

Position Information Posting NumberSRGV8742 Working TitleMedical Assistant Number of Vacancies1 LocationEdinburg, Texas DepartmentSchool of Medicine / Neuro & Behavioral Health ISU FTE1.0 FLSANon-Exempt Scope of Job...

4h ago

Go to Apply