Medical Director ( OBGYN /Based in MS)- Part Time

Molina Healthcare • Southaven, MS • 6h 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.

*Position is remote in Mississippi

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 (MS) of practice.

Board certification-specialty in Obstetrics and Gynecology.

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: $93,100 - $181,465 / ANNUAL

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

Similar Jobs

Medical Support Assistant

Veterans Affairs, Veterans Health Administration • Memphis, TN • 7h ago

Hospital & Medical

Summary The incumbent serves as a Medical Support Assistant in the Business Office for the Memphis VA Medical Center and will provide support to the Inpatient Ward, Emergency Room, Baggage Claims, Environmental Care and...

7h ago

Go to Apply

Registered Nurse

Actalent • Memphis, TN • 9h ago

Hospital & Medical

Job Title: Registered NurseJob Description The Registered Nurse will provide wound care treatment for patients in the unit, ensuring high-quality patient care and clinical outcomes. Responsibilities Access and deliver wo...

9h ago

Go to Apply

Emergency Medical Technician - Manufacturing

GardaWorld • Marion, AR • 1d ago

Hospital & Medical

Job Description Emergency Medical Technician (EMT - Now Hiring! You've got the right skills. What you need is the right opportunity to unleash your potential. We agree, and we're hiring! At GardaWorld, we know your compe...

1d ago

Go to Apply

Healthcare Customer Project Manager - Based near Memphis or Little Rock

Philips • Memphis, TN • 1d ago

Hospital & Medical

Serve the healthcare community through effective and efficient management of capital medical equipment installations and IT solution implementation at various stages across the healthcare continuum for the Philips Health...

1d ago

Go to Apply

Registered Nurse-Operating Room

Veterans Affairs, Veterans Health Administration • Memphis, TN • 1d ago

Hospital & Medical

Summary The Registered Nurse is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assumes responsibility for the coordination of care focused on pa...

1d ago

Go to Apply

Register Respiratory Therapist

Veterans Affairs, Veterans Health Administration • Memphis, TN • 1d ago

Hospital & Medical

Summary The Register Respiratory Therapist work independently providing respiratory care in both inpatient and/or outpatient settings. The specific assignments are dependent on facility structure and complexity levels. T...

1d ago

Go to Apply

Resource Director of Nursing (Travel)

Signature Healthcare • Memphis, TN • 3d ago

Hospital & Medical

Signature HealthCARE is a family-based healthcare company offering integrated services across multiple states. Our continuum of care includes skilled nursing, rehabilitation, assisted and memory care, and home-based serv...

3d ago

Go to Apply

Physician (Cardiothoracic Surgeon)

Veterans Affairs, Veterans Health Administration • Memphis, TN • 5d ago

Hospital & Medical

Summary The Lt. Col. Luke Weathers, Jr., VAMC in Memphis, TN is recruiting for an Cardiothoracic Surgeon to serve as a full-time surgical care physician. The position is accountable to the Chief of Surgery, for assuring...

5d ago

Go to Apply

Nursing Assistant-Mental Health

Veterans Affairs, Veterans Health Administration • Memphis, TN • 5d ago

Hospital & Medical

Summary The Nursing Assistant functions as a member of the nursing care team and assist licensed nursing staff in the care of patients/residents receiving preventive, acute, sub-acute chronic, maintenance, and hospice ca...

5d ago

Go to Apply

Physical Therapist

U.S. Physical Therapy • Southaven, MS • 6d ago

Hospital & Medical

Company Description At Memphis Physical Therapy, we're proud to offer excellent physical therapy in Southaven, Mississipp i ! We're a vibrant and progressive clinic that values creativity, collaboration, and pushing the...

6d 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.