Medical Director (Medicare)

Molina Healthcare • Long Beach, CA • 2h 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: $186,201.39 - $363,092.71 / ANNUAL

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

Similar Jobs

Medical Billing Specialist

Robert Half • La Puente, CA • 2h ago

Hospital & Medical

Description A Larger Medical Center in the La Puente Area is in the need of a d Medical Billing Specialist with strong Medi-Cal insurance experience. The Medical Billing Specialist will play a key part in managing the re...

2h ago

Go to Apply

Amazon Connect Technical Lead / Developer

Deloitte • Costa Mesa, CA • 3h ago

Hospital & Medical

Our Deloitte Sales & Service team empowers organizations to build deeper relationships with customers through innovative strategies, advanced analytics, Generative AI, transformative technologies, and creative design...

3h ago

Go to Apply

Pharmacy Operations Manager

Walgreens • Santa Monica, CA • 3h 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...

3h ago

Go to Apply

Amazon Connect Technical Lead / Developer

Deloitte • Los Angeles, CA • 3h ago

Hospital & Medical

3h ago

Go to Apply

INFORMATION TECHNOLOGY MANAGER I / Emergency Appointment Fire

The County of Los Angeles • Los Angeles, CA • 12h ago

Hospital & Medical

INFORMATION TECHNOLOGY MANAGER I / Emergency Appointment Fire Print ( https://www.governmentjobs.com/careers/lacounty/jobs/newprint/5242942 ) ? INFORMATION TECHNOLOGY MANAGER I / Emergency Appointment Fire Salary $132,00...

12h ago

Go to Apply

Oracle Services - Industrials Sector Leader -Senior Manager - Tech Consulting - Open Location

EY • Los Angeles, CA • 17h ago

Hospital & Medical

Location: Anywhere in Country At EY, we're all in to shape your future with confidence. We'll help you succeed in a globally connected powerhouse of diverse teams and take your career wherever you want it to go. Join EY...

17h ago

Go to Apply

Patient Service Rep - Vascular Surgery

Cedars-Sinai • Beverly Hills, CA • 18h ago

Hospital & Medical

Job Description The Patient Service Rep is responsible for positive patient relations, accurate telephone communication, appointment scheduling, patient registration, payment and co-payment collection and overall providi...

18h ago

Go to Apply

Licensed Vocational Nurse

Sevita • Long Beach, CA • 20h ago

Hospital & Medical

Mentor Community Services , a part of the Sevita family, provides community-based services for individuals with intellectual and developmental disabilities. Here we believe every person has the right to live well, and ev...

20h ago

Go to Apply

Physical Therapist (PT)

Genesis Healthcare • Torrance, CA • 21h ago

Hospital & Medical

Overview At Powerback, we're on a mission to improve lives. As the leader in physical, occupational, speech, and respiratory therapies, we help older adults stay active and thrive while providing essential therapy for ch...

21h ago

Go to Apply

Physical Therapist - Up to $20,000 Sign On

Select Medical • Cypress, CA • 21h ago

Hospital & Medical

Overview Outpatient Physical Therapist Cypress, CA Up to $20,000 Sign On Bonus Monthly Student Loan Repayment Assistance Clinic Details: Select Physical Therapy in Cypress, CA is looking for a full time orthopedic PT to...

21h 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.