Medical Director (Medicare)

Molina Healthcare • Lexington, KY • 2d 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

Supervisory Biomedical Engineer (Clinical)

Veterans Affairs, Veterans Health Administration • Lexington, KY • 5h ago

Hospital & Medical

Summary The Supervisory Biomedical Engineer (Clinical) functions as the Chief Biomedical Engineer (CBE) and is responsible for the professional and administrative management of the Healthcare Technology Management at Lex...

5h ago

Go to Apply

General Lead Health Information Specialist

Datavant • Frankfort, KY • 10h ago

Hospital & Medical

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format. Our platform is power...

10h ago

Go to Apply

Home Health Physical Therapist Assistant

HCA Healthcare • Lexington, KY • 2d ago

Hospital & Medical

Description Introduction Experience the HCA Healthcare difference where colleagues are trusted, valued members of our healthcare team. Grow your career with an organization committed to delivering respectful, compassiona...

2d ago

Go to Apply

Director, Finance (NY Health Plan) - REMOTE

Molina Healthcare • Lexington, KY • 2d ago

Hospital & Medical

JOB DESCRIPTION Job Summary Leads and directs team responsible for finance activities including financial analysis, reporting, forecasting, trending and modeling. Duties include interpreting and evaluating information fo...

2d ago

Go to Apply

Dialysis Clinical Manager Registered Nurse - RN

Fresenius Medical Care • Georgetown, KY • 2d ago

Hospital & Medical Sponsored

PURPOSE AND SCOPE: Supports FMCNA’s mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. Ensure provision...

2d ago

Go to Apply

Advanced Practice Nurse Endocrinology

Veterans Affairs, Veterans Health Administration • Lexington, KY • 3d ago

Hospital & Medical

Summary The Advanced Practice Nurse (APN) Certified Endocrinology Nurse Practitioner (NP) practices in Medicine Service to provide a full range of services emphasizing quality, timeliness, and the advancement of the Vete...

3d ago

Go to Apply

Physical Therapist

CommonSpirit Health at Home • Lexington, KY • 3d ago

Hospital & Medical

Job Summary and Responsibilities We are seeking a skilled and compassionate Physical Therapist to join the VNA Health at Home team. The successful candidate will provide physical therapy services to patients in their hom...

3d ago

Go to Apply

Nurse Clinical/UKHC

University of Kentucky • Lexington, KY • 3d ago

Hospital & Medical

University of KentuckyEqual Employment Opportunity/M/F/disability/protected veteran status.Posting Details Posting Details Job TitleNurse Clinical/UKHCRequisition NumberNR14567Working TitleRN/ Pediatric Acute Care West/K...

3d ago

Go to Apply

Product Owner, Health Sciences, Consulting Manager

Cognizant • Frankfort, KY • 3d ago

Hospital & Medical

About the Role As a Product Owner for Sales & Enrollment Platforms, you will make an impact by leading the development and optimization of Elv Sales and Enrollment capabilities. You will be a valued member of the Sal...

3d ago

Go to Apply

Senior Analyst, Finance Operations (Medical Supplier Agreements)

Cardinal Health • Frankfort, KY • 3d ago

Hospital & Medical

What Finance Operations contributes to Cardinal Health Finance oversees the accounting, tax, financial plans and policies of the organization, establishes and maintains fiscal controls, prepares and interprets financial...

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.