KNOWLEDGE/SKILLS/ABILITIES

Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

• 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, P&T and others 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, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensures that 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 the Primary Care Physician and Specialty networks. Monitor’s practitioner practice patterns and recommends corrective actions if needed.
• Works with Contracting Department in contract negotiation.
• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
• Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.
• Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

Required Education

• Doctorate Degree in Medicine
• Board Certified or eligible in a primary care specialty

Required Experience

• 7 - 9 years relevant experience, including:
• 5+ years clinical practice.
• 2 years previous experience as a Medical Director.
• 3 years’ experience in Utilization/Quality Program management.
• 2+ years HMO/Managed Care experience.
• Current clinical knowledge.
• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.
• Knowledge of applicable state, federal and third-party regulations

Required License, Certification, Association

Current CA state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.

Preferred Education

Master's in Business Administration, Public Health, Healthcare Administration, etc.

Preferred Experience

• Peer Review, medical policy/procedure development, provider contracting experience.
• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

Preferred License, Certification, Association

Board Certification (Primary Care preferred).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

https://careers.molinahealthcare.com/job/united-states/medical-director-ca-health-plan/21726/28721867168