Medical Director (CA)

Molina Healthcare • Sacramento, 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 - $363,093 / ANNUAL

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

Similar Jobs

Registered Nurse, Psychiatry

Sutter Health • Sacramento, CA • 1h ago

Hospital & Medical

We are so glad you are interested in joining Sutter Health! Organization: SCP-Sutter Center for Psychiatry Position Overview: The Registered Nurse in the Mental Health setting manages the patient/family experience throug...

1h ago

Go to Apply

Physical Therapist - PRN

Select Medical • Sacramento, CA • 4h ago

Hospital & Medical

Overview Physical Therapist - Outpatient PRN Sacramento, CA Select Physical Therapy in the Sacramento, CA Market is seeking coverage of an outpatient physical therapist for our highly respected orthopedic team. We treat...

4h ago

Go to Apply

Care Manager, Telephonic Behavioral Health

Humana • Sacramento, CA • 1d ago

Hospital & Medical

Become a part of our caring community The Telephonic Care Manager will be part of the Humana Military Case Management team, providing a comprehensive, holistic approach for Behavioral Health Case Management throughout th...

1d ago

Go to Apply

Account Executive - Healthcare

SHI • Sacramento, CA • 1d ago

Hospital & Medical

About Us Since 1989, SHI International Corp. has helped organizations change the world through technology. We've grown every year since, and today we're proud to be a $16 billion global provider of IT solutions and servi...

1d ago

Go to Apply

Account Executive, Wound Closure - Sacramento, CA - Johnson & Johnson MedTech, Surgery

J&J Family of Companies • Sacramento, CA • 1d ago

Hospital & Medical

At Johnson & Johnson,?we believe health is everything. Our strength in healthcare innovation empowers us to build a?world where complex diseases are prevented, treated, and cured,?where treatments are smarter and les...

1d ago

Go to Apply

Senior Medical Analyst

Norstella • Sacramento, CA • 1d ago

Hospital & Medical

Senior Medical Analyst Company: Norstella Location: Remote, United States Date Posted: Jun 1, 2026 Employment Type: Full Time Job ID: R-1999 Description At Norstella, we are on a mission to help our clients bring life-sa...

1d ago

Go to Apply

Physical Therapist II, Ambulatory

Sutter Health • Roseville, CA • 1d ago

Hospital & Medical

We are so glad you are interested in joining Sutter Health! Organization: SMF-Sutter Med Foundation- Central Position Overview: Independently responsible for assessing, planning, organizing, and participating in rehabili...

1d ago

Go to Apply

Physical Therapist II, Ambulatory

Sutter Health • Lincoln, CA • 1d ago

Hospital & Medical

1d ago

Go to Apply

E-Referral Specialist Home Health

CenterWell • Sacramento, CA • 1d ago

Hospital & Medical

Become a part of our caring community Shift/Availability Requirements: This is a full-time position scheduled for 40 hours, 5 days a week. Days/hours of availability: Monday-Friday from 9am-5:30pm EST. Available to work...

1d ago

Go to Apply

Physical Therapist II, Rehab Institute, Float

Sutter Health • Roseville, CA • 1d ago

Hospital & Medical

We are so glad you are interested in joining Sutter Health! Organization: SRMC-Sutter Roseville Med Center Position Overview: Responsible for assessing, planning, organizing, and participating in rehabilitative programs...

1d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)